🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-08-06 18:07:45
Transcript
ADG SCRIBE — FINALIZED BILLING CODING DOCUMENT ==================================================== Session ID: e0a620d5-6b4b-4253-83c9-61327214675b Generated at: 2026-08-04T20:15:50.569239+00:00 Finalized by: Sohang Tyagi Patient: Tyagi, Sohang Patient ID: 00052 SELECTED ICD-10 DIAGNOSIS CODES -------------------------------- (none selected) SELECTED CPT PROCEDURE CODES -------------------------------- - 99214 (mod 25) — Office or other outpatient visit for the evaluation and management of an established patient — est. $200.00 (confidence: high) Reasoning: The patient's detailed history, examination, and medical decision-making support a level 4 established patient visit. Transcript evidence: I’ve been experiencing persistent headaches for the past three weeks. Along with that, I’ve been feeling dizzy occasionally, especially when I stand up quickly. I’ve also noticed that I’m getting tired much faster than usual. Symptoms/findings: headaches; dizziness; fatigue Justification: The complexity of the patient's symptoms and the need for further evaluation warrant a level 4 established patient visit. BILLING EVIDENCE SUMMARY -------------------------------- - [CPT] 99214 (SELECTED, confidence: high) Clinical reasoning: The patient's detailed history, examination, and medical decision-making support a level 4 established patient visit. Transcript excerpt: I’ve been experiencing persistent headaches for the past three weeks. Along with that, I’ve been feeling dizzy occasionally, especially when I stand up quickly. I’ve also noticed that I’m getting tired much faster than usual. Symptoms/findings: headaches; dizziness; fatigue Justification: The complexity of the patient's symptoms and the need for further evaluation warrant a level 4 established patient visit. DISCLAIMER -------------------------------- CPT estimated_price values are AI estimates only and are not from a billing fee schedule. Replace with fee-schedule amounts before claim submission. This document was generated by ADG Scribe for session billing reference.
Clinical Notes
SOAP Clinical Note
Subjective
The patient, Sohang Tyagi, reports experiencing persistent headaches for the past three weeks. Additionally, he mentions feeling dizzy occasionally, especially when standing up quickly. He also notes increased fatigue, stating that he is getting tired much faster than usual.
Objective
No specific objective findings are documented in the transcript.
Assessment
The patient presents with symptoms of persistent headaches, dizziness, and fatigue. The complexity of these symptoms suggests the need for further evaluation to determine the underlying cause.
Plan
Further evaluation is required to assess the cause of the patient's symptoms. No specific medications or treatments are documented in the transcript.