SAMPLE / SIMULATED ENCOUNTER - generated from a role-play intake for demonstration only.
Not a medical record and not for clinical use.
Clinical Note (SOAP)
S - Subjective
History of present illness
60-year-old woman with hot flashes for about 5 years. Onset coincided with menopause at age 55
(no menses since). Symptoms have persisted continuously since onset. Reports drenching night
sweats. Denies fever, unintentional weight loss and swollen glands. Denies palpitations, tremor,
heat intolerance between episodes, chest pain and shortness of breath. Reports urinary urgency.
Medications
- Multivitamin, daily. No prescription or other over-the-counter medications.
Past medical history
- No personal history of breast cancer.
Family history
- Mother: breast cancer, diagnosed at age 40 (premenopausal).
Health maintenance
- Last mammogram about 5 years ago (overdue).
Review of systems
| System | Positive | Negative |
|---|
| Constitutional | Night sweats | Fever, weight loss |
| Endocrine | Hot flashes | Heat intolerance, tremor |
| Cardiovascular / respiratory | - | Palpitations, chest pain, dyspnea |
| Genitourinary | Urinary urgency | - |
| Lymphatic | - | Lymphadenopathy |
Not yet obtained (complete at next contact)
- History of blood clot, stroke or clotting disorder
- Smoking status; hypertension, diabetes, hyperlipidemia
- Frequency and severity of hot flashes; effect on sleep and function
- Urinary leakage, vaginal dryness, dyspareunia, recurrent UTIs
- Interest in hormone or non-hormonal therapy
- Allergies, OB/GYN history, other family history (ovarian, other cancers)
O - Objective
- Vitals: not recorded in this simulated encounter (BP, HR, temp, weight, BMI).
- Physical exam: not documented. Recommended focus: thyroid, lymph nodes,
breast exam, cardiovascular, and pelvic exam for atrophic changes.
- Labs / imaging: ordered, results pending (see Plan).
A - Assessment
| # | Problem | ICD-10-CM | ICD-11 | Comment |
|---|
| 1 | Menopausal vasomotor symptoms, persistent 5 years | N95.1 | GA30.4 |
Onset at menopause and continuous since; typical pattern. Most likely cause. |
| 2 | Night sweats | R61 | - |
Likely vasomotor. No other systemic symptoms; basic labs to exclude other causes. |
| 3 | Urinary urgency | R39.15 | - |
Suspect genitourinary syndrome of menopause. Rule out infection. |
| 4 | Family history of breast cancer (mother, age 40) | Z80.3 | - |
Meets common criteria for genetic risk evaluation. Late menopause (55) adds modest risk.
Relevant to any hormone therapy decision. |
| 5 | Overdue screening mammogram | Z12.31 | - |
Last study about 5 years ago. |
US claims use ICD-10-CM. ICD-11 codes are shown for reference and should be verified in the WHO ICD-11 browser.
P - Plan
Orders
| Test | CPT | Linked diagnosis | Reason |
|---|
| Screening mammogram, bilateral | 77067 | Z12.31, Z80.3 | Overdue; required before any hormone therapy |
| TSH | 84443 | R61, N95.1 | Exclude thyroid cause of sweating and flushing |
| CBC with differential | 85025 | R61 | Drenching night sweats |
| Urinalysis, automated | 81003 | R39.15 | Exclude urinary tract infection |
Not ordered: FSH and estradiol (would not change management at age 60), ECG (no cardiac symptoms).
Referrals
- Gynecology, Dr. Johnson (incontinence) - provisional, pending results. Vasomotor symptoms plus urinary urgency.
- Gynecology, Dr. Smith (breast cancer) - consult if hormone therapy is considered, given family history.
- Genetic counseling / cancer genetics (not on the panel list) - first-degree relative with breast cancer before age 50.
Counseling and follow-up
- Discussed that the pattern fits menopause; tests are to rule out other causes.
- Treatment discussion deferred until mammogram, clot and cardiovascular history are known.
Non-hormonal options may be preferred given family history.
- Return precautions: fever, weight loss, new lumps, burning with urination, blood in urine.
- Follow-up visit or call to review results in 1 to 2 weeks.
Charge Capture
Bill now - supported by this note
Higher-level alternative - needs more time or documentation
Conditional - only if results or answers trigger it
Not recommended for this case
High well supported by current data
Medium plausible, depends on missing facts
Low unlikely to apply or be paid
Dx pointers:
A N95.1 menopausal states ·
B R61 night sweats ·
C R39.15 urinary urgency ·
D Z80.3 family hx breast cancer ·
E Z12.31 screening mammogram
This visit, as documented
~$342
Medicare national, all entities. Office share ~$180.
If upgraded to 99205 + G2211
~$419
Requires 60+ min or high MDM documented
Conditional add-ons (max)
~$93
Lab and office codes only; excludes BRCA testing
Bill nowSupported by this note
| Code | Description | Dx | Billed by | Medicare | Commercial est. | Confidence | Why |
|---|
| 99204 | New patient visit, moderate MDM (or 45+ min) | A, B, C, D | Office |
$177.36 | $213-319 | Med-High |
Problems moderate (new undiagnosed problem: night sweats, urgency) + data moderate (4 unique tests ordered). Auditors may challenge the problem element; 99203 ($117.57) is the safe floor. |
| 36415 | Venipuncture | A, B | Office (if drawn on site) |
~$3 | $4-5 | High |
Needed for TSH and CBC. |
| 84443 | TSH | B, A | Lab |
~$17 | $20-30 | High |
Standard rule-out for sweating and flushing. Routinely covered. |
| 85025 | CBC with differential | B | Lab |
~$8 | $9-14 | High |
Drenching night sweats documented. |
| 81003 | Urinalysis, automated, no microscopy | C | Office or lab |
~$2 | $3-4 | High |
Urgency documented; rules out infection. |
| 77067 | Screening mammogram, bilateral, with CAD | E, D | Radiology |
~$135 | $162-243 | High |
Overdue 5 years. Preventive benefit, usually no cost-share. |
Higher-level alternativesLonger visit, more workup or added services
| Code | Description | Dx | Medicare | Commercial est. | Confidence | What it would take |
|---|
| 99205 | New patient visit, high MDM (or 60+ min) | A-D |
$236.81 | $284-426 | Low |
60+ min total time on the date (history, exam, counseling, documentation), or high MDM. High risk would need, for example, a hormone therapy decision in a patient with high clot or cancer risk. Not supported by the current note. |
| 99417 | Prolonged service, each 15 min beyond 99205 | A-D |
~$33 | $40-59 | Low |
Commercial payers. 75+ min total time, only with 99205. Medicare uses G2212 instead (89+ min); patient is under 65. |
| G2211 | Visit complexity add-on (longitudinal care) | A |
$17.37 | Payer-dependent | Medium |
Valid only if this office will stay the continuing focal point of her care. Medicare and some commercial plans. CMS has proposed turning it into a modifier for 2027. |
| 99386-25 pairing | Preventive visit, new patient, age 40-64 (with problem visit modifier 25) | Z00.00/Z00.01, E |
n/a | $150-250 | Medium |
If a full preventive exam is done the same day: overdue screenings, age-based counseling. Commercial plans pay it with no cost-share. Problem visit would then drop to 99203-25 or 99204-25. |
| 99401 | Preventive counseling, ~15 min | D |
~$33 | $40-59 | Low |
Hereditary breast cancer risk counseling before the genetics referral. Often bundled into the visit and denied; separate time must be documented. |
Conditional - order only if triggeredConfidence reflects the chance it becomes needed, given what we know now
| Code | Description | Trigger | Medicare | Commercial est. | Confidence | Why |
|---|
| 80061 | Lipid panel | Hormone therapy considered, or CV risk factors |
~$13 | $16-24 | Medium |
Last intake question (clots, smoking, BP, diabetes) is unanswered. Also a routine screen at 60 if not done recently. |
| 87086 | Urine culture, colony count | Urinalysis positive |
~$8 | $10-14 | Medium |
Urgency present. Most urgency at this age is non-infectious. |
| 51798 | Post-void residual, bladder ultrasound | Urgency persists, infection ruled out |
~$20 | $24-36 | Medium |
Standard urgency workup. Often done by the urogynecologist (Dr. Johnson) instead. |
| 83036 | Hemoglobin A1c | Diabetes risk, overweight, or hormone therapy considered |
~$10 | $12-17 | Medium |
Depends on BMI and the unanswered risk-factor question. |
| 80053 | Comprehensive metabolic panel | Abnormal CBC, or before starting treatment |
~$11 | $13-19 | Low |
No current symptom requires it. |
| 84439 | Free T4 | TSH abnormal |
~$9 | $11-16 | Low |
No thyroid symptoms reported. |
| 83615 | LDH | CBC abnormal |
~$6 | $7-11 | Low |
No fever, weight loss or nodes. |
| 93000 | ECG with interpretation | Cardiac symptoms or high CV risk before hormone therapy |
~$16 | $19-29 | Low |
No palpitations, chest pain or dyspnea. |
| 81162 | BRCA1/BRCA2 sequencing + deletion/duplication | After genetic counseling recommends testing |
Lab-priced | Varies widely | Medium |
Mother diagnosed at 40 meets common testing criteria. Usually ordered by genetics, with prior authorization. |
Not recommendedLikely denied or no clinical value here
| Code | Description | Medicare | Confidence | Why not |
|---|
| 83001 / 82670 | FSH / estradiol | ~$18 / ~$28 | Low |
Menopause is a clinical diagnosis at 60. Results would not change management. |
| 77065 / 77066 | Diagnostic mammogram | - | Low |
No breast symptoms or findings. Family history alone stays screening (77067). |
| G0101 | Pelvic and breast cancer screening exam | - | Low |
Medicare-only code; patient is 60. |
E/M level support (2021+ MDM rules)
| Element | Documented | Level |
|---|
| Problems | Persistent vasomotor symptoms; new night sweats and urinary urgency, cause not yet known | Moderate |
| Data | 4 unique tests ordered (TSH, CBC, UA, mammogram) | Moderate |
| Risk | Tests and referrals only; no prescription management yet | Low |
| Result | 2 of 3 elements at moderate | Moderate - 99204 |
Amounts are estimates. E/M and G2211 figures are 2026 Medicare national non-facility rates without geographic
adjustment; lab and imaging figures are approximate Clinical Lab Fee Schedule and Physician Fee Schedule values.
Commercial estimates assume 120-180% of Medicare. Actual payment depends on locality, payer contract, deductible and
place of service. Verify against your MAC fee schedule and payer contracts before use. Lab and imaging lines are billed
by the performing entity, not the ordering office.
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Date / time