Patient presents for follow-up post renal transplant.  The patient received a deceased donor kidney transplant approximately [Number] months/years ago.  Current medications include [List medications including immunosuppressants, antihypertensives, etc.].  Review of systems reveals [Document patient-reported symptoms e.g., fatigue, pain, changes in urine output].  Physical examination reveals stable vital signs, surgical site well-healed, no palpable masses or tenderness.  Laboratory results including serum creatinine, BUN, GFR, and urine analysis are reviewed and indicate [Describe lab findings; e.g., stable renal function, signs of rejection, infection].  Immunosuppressant levels are within therapeutic range.  Assessment:  Stable renal allograft function.  Plan: Continue current immunosuppression regimen.  Patient education provided regarding medication compliance, signs and symptoms of rejection, and infection prevention.  Follow-up scheduled in [Timeframe] for ongoing monitoring of renal transplant function, including laboratory evaluation and clinical assessment.  Differential diagnoses considered included acute rejection, chronic allograft nephropathy, infection, and drug toxicity.  ICD-10 code Z94.0, kidney transplant status, is documented.  CPT codes for evaluation and management services, as well as applicable laboratory and medication management codes, will be billed accordingly.