CC: I’m having hot flashes and mood swings.
HPI: 51-year-old Black female in menopause for 1 year. Reports frequent hot flashes and sleep disturbance. Denies vaginal bleeding. Not on HRT. Seeks non-hormonal options.
CPT: 99214 (Established, moderate complexity)
ICD: N95.1 (Menopausal and perimenopausal disorder)
Complexity: Moderate
Race: Black/African American
Visit: Follow-up