diff --git "a/formatted_data.json" "b/formatted_data.json" new file mode 100644--- /dev/null +++ "b/formatted_data.json" @@ -0,0 +1,25002 @@ +[ + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Right knee pain\n\nHISTORY: 45-year-old presents with 1 week of right knee pain \nafter hiking. Pain worse with stairs. No trauma. No swelling or instability.\n\nVITALS: BP 124/78, HR 70\n\nPHYSICAL EXAM:\n- Right knee: No effusion, full range of motion\n- Tenderness over medial joint line\n- Negative McMurray test\n- No ligamentous laxity\n\nASSESSMENT: Right knee strain, likely medial meniscus irritation\n\nPLAN:\n- NSAIDs for 1-2 weeks\n- Ice and rest\n- Physical therapy referral if no improvement\n- Consider MRI if symptoms persist > 4 weeks", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"M25.561\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Diabetes management\n\nHISTORY: 62-year-old with type 2 diabetes mellitus presents for \nroutine follow-up. Currently on metformin 1000mg BID. \nRecent HbA1c was 7.2%. No hypoglycemic episodes.\n\nVITALS: BP 132/82, HR 76, Weight 195 lbs, BMI 29.6\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rhythm\n- Extremities: No ulcers, pedal pulses intact\n- Monofilament exam: Intact sensation\n\nASSESSMENT: Type 2 diabetes mellitus, adequate control\n\nPLAN:\n- Continue metformin 1000mg BID\n- Recheck HbA1c in 3 months\n- Referred to dietitian for nutrition counseling\n- Annual diabetic eye exam scheduled", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99214\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"E11.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Well-child check\n\nHISTORY: 6-year-old male presents for routine well-child examination.\nParent reports child is doing well in school. No concerns.\n\nVITALS: BP 98/62, HR 88, Temp 98.6\u00b0F, Weight 48 lbs, Height 46 inches\n\nPHYSICAL EXAM:\n- General: Well-appearing, interactive\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm\n- Respiratory: Clear bilaterally\n- Abdomen: Soft, non-tender\n- Development: Age-appropriate\n\nIMMUNIZATIONS: Up to date\n\nASSESSMENT: Routine well-child care\n\nPLAN:\n- Discussed nutrition, safety, development\n- No immunizations needed today\n- Return for 7-year well-child visit", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99393\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.129\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Annual physical examination\n \nHISTORY: 45-year-old established patient presents for routine annual physical. \nNo new complaints. Patient reports feeling well overall.\n\nVITALS: BP 122/78, HR 72, Temp 98.4\u00b0F, Weight 165 lbs, Height 5'8\"\n\nPHYSICAL EXAM:\n- General: Alert and oriented, no acute distress\n- HEENT: Normal\n- Cardiovascular: Regular rate and rhythm, no murmurs\n- Respiratory: Clear to auscultation bilaterally\n- Abdomen: Soft, non-tender\n\nASSESSMENT: Routine health maintenance\n\nPLAN:\n- Ordered comprehensive metabolic panel, lipid panel, CBC\n- Discussed diet and exercise\n- Continue current medications\n- Follow up in 1 year", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99395\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"Z00.00\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Sore throat and congestion\n\nHISTORY: 32-year-old patient presents with 3 days of sore throat, \nnasal congestion, and mild cough. No fever. No chest pain or shortness of breath.\n\nVITALS: BP 118/76, HR 68, Temp 98.2\u00b0F\n\nPHYSICAL EXAM:\n- General: No acute distress\n- HEENT: Erythematous pharynx without exudate, nasal congestion\n- Neck: No lymphadenopathy\n- Lungs: Clear bilaterally\n\nASSESSMENT: Acute upper respiratory infection, likely viral\n\nPLAN:\n- Symptomatic treatment with rest, fluids\n- OTC decongestants and throat lozenges\n- Return if symptoms worsen or persist > 7 days", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"J06.9\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + }, + { + "instruction": "Analyze this clinical note and suggest appropriate CPT and ICD-10 medical codes. Provide the codes in JSON format with confidence scores and reasoning.", + "input": "CHIEF COMPLAINT: Hypertension follow-up\n\nHISTORY: 58-year-old with essential hypertension returns for \nblood pressure check. Currently on lisinopril 10mg daily. \nCompliant with medications. No side effects.\n\nVITALS: BP 138/86, HR 74, Weight 180 lbs\n\nPHYSICAL EXAM:\n- Cardiovascular: Regular rate and rhythm\n- No peripheral edema\n\nASSESSMENT: Essential hypertension, improving control\n\nPLAN:\n- Continue lisinopril 10mg daily\n- Recheck BP in 3 months\n- Encouraged DASH diet and regular exercise", + "output": "{\n \"cpt_codes\": [\n {\n \"code\": \"99213\",\n \"confidence\": 0.95,\n \"reasoning\": \"Clinical documentation supports this procedure code\"\n }\n ],\n \"icd_codes\": [\n {\n \"code\": \"I10\",\n \"confidence\": 0.95,\n \"reasoning\": \"Diagnosis clearly documented in clinical note\"\n }\n ]\n}" + } +] \ No newline at end of file