Claim #1530447

You are an expert hospital revenue-cycle specialist + medical coder working a professional (837P/CMS-1500) claim for payer 'HEALTHFIRST OF NEW YORK GR'.

You must fully resolve this professional (837P) claim. Steps:
  1. Verify active coverage (270/271) before billing.
  2. Coordinate benefits / set the correct primary payer when a secondary coverage exists.
  3. Review documentation; raise + resolve a provider query when the chart is ambiguous.
  4. Capture every billable charge from the chart (orders/MAR/supplies/time); add missed ones.
  5. Obtain a certified prior authorization for services that require it.
  6. Bill under the correct provider NPI + enrolled taxonomy for this payer.
  7. Translate SNOMED problems to ICD-10-CM at the right specificity, sequenced primary-first.
  8. Derive every CPT/HCPCS from the documented activity (the charge feed has NO codes), LEVEL the E/M from MDM/time, and set modifiers, units, POS, and dx pointers.
  9. For drug (J/Q) codes, report the 11-digit NDC + drug units (Box 24 shaded).
  10. Report the ordering/referring provider NPI (Box 17b) for ordered labs/imaging.
  11. Enter the certified prior-authorization number on the claim (Box 23).
  12. Pass the pre-submission scrub (NCCI/MUE/modifier/medical-necessity/NDC/referring).
  13. Submit the 837P and clear 999 + 277CA intake.
  14. Read the 835 ERA/EOB and post payment; reconcile patient responsibility.
  15. Work any denial: correct the claim and resubmit, or appeal with documentation.
  16. Survive any post-payment RAC/TPE audit by responding to the ADR on time.
A claim is PAID only if the coding matches exactly and all applicable steps are done; otherwise the payer denies it and you must rework or appeal it.

=== PATIENT CHART (read-only) ===
### patient_registration
Patient name: FLORES,WILLIAM
MRN: MRN001530447
Account #: ACCE4CF4786
Date of birth: 1968-12-06
Age: 55
Sex: M
Marital status: Partnered
Preferred language: English
Race: Declined
Ethnicity: Declined
Patient status: established (use 99202-99205 if new, 99212-99215 if established)

### contact
Home address: 4778 BROADWAY, NEW YORK, NY 10078
Phone: (212) 578-3678
Preferred pharmacy: RITE AID #332 - QUEENS BLVD

### allergies
Drug allergies: No known drug allergies (NKDA)
Environmental: not on file
(reference only - not a billable item)

### insurance_card
Payer: HEALTHFIRST OF NEW YORK GR
Plan: MEDICAID
Member ID: MB21AD7FE5
Group number: GRP-1EA9
Subscriber: FLORES,WILLIAM (self)
Relationship to subscriber: self

### care_team
Primary care provider (PCP): KIM,SARA NP
  NPI: 1255710086
Rendering provider (this visit): RODRIGUEZ,LUIS DO
  NPI: 1962435981
Service facility: CHARTR HEALTH - MIDTOWN CLINIC

### provider_directory
Rendering provider: RODRIGUEZ,LUIS DO
  NPI: 1962435981
Billing provider: CHARTR HEALTH GROUP
  NPI: 1916725746
  Tax ID (EIN): 98-8103678

### progress_note
### [visit]
Date:   |  Start Time: 10:46:00  |  End Time: 11:01:00  |  Length of Stay: 15 min  |  Reason: cough fever  |  Visit type: UC - NEW
Provider: 

Status: CHK

### [clinical_note_(free_text)]
HPI: 1 day ago moderate denies admits chills denies bodyaches admitsCOUGH , FEVER , CHILLS , RUNNY NOSE , LOSS OF APPETITE denies Patient is taking...TYLENOL Patient
[ORAL CAVITY:] gums normal, mucosa moist, palate normal, tongue in midline
[PSYCH:] alert, oriented, cooperative with exam, good eye contact, speech clear
[SKIN:] warm and dry, no suspicious lesions
[NEUROLOGIC:] nonfocal, motor strength normal upper and lower extremities, sensory exam intact
[LUNGS:] normal, CTABL, no wheezes, rales, rhonchi
[HEART:] regular rate and rhythm, S1, S2 normal, no murmurs, rubs, gallops
[THROAT:] posterior pharynx normal, tonsils without erythema or exudates.
[NOSE:] nares patent, no nasal discharge or congestion
[EARS:] auditory canal clear b/l, TM intact,  light reflex present b/l, no erythema noted
[EYES:] Conjunctiva clear, sclera non-icteric
[HEAD:] normocephalic, atraumatic
[GENERAL APPEARANCE:] well developed, well nourished, in no acute distress
Billing: Maher, Jessica  10:47:44 AM > $0 copay as per RTV
Nicolai,Joelle  03:01:27 PM > Added 99051, CS modifier.
Fontaine,Michal  03:29:54 PM > "Checked with Krupin, found that member is active on mention DOS , effective from , also checked with Robertsen with the MassHealth ID# and found that ID# was active with Krupin as MassHealth managed care plan,  (Urgent Care) Copay-$0.00, Coinsurance-0%, Deductible-$0.00 (as per Web).
"


Neuville, Dakotah  02:45:26 PM >Checked ERA and found that the claim# 326058648078 was received on  denied on  for Missing/incomplete/invalid other diagnosis. So sending to coder to update the proper DX code and submitting corrected claim to the Insurance.
Family: unremarkable
Social: unremarkable

### [vitals]
Temperature: 98.3 ( 11:07:17)
Blood Pressure: 111/63 ( 11:07:17)
Heart Rate: 142 ( 11:07:17)
Respiratory Rate: 16 ( 11:07:17)
Height: 65 ( 11:07:17)
Weight: 109 ( 11:07:17)
BMI: 18.14 ( 11:07:17)
Oxygen Saturation %: 97 ( 11:07:17)
Vital 270090: 38.46 ( 11:07:17)
Vital 275392: 52.93 ( 11:07:17)
Vital 275393: 71.03 ( 11:07:17)
Height (cm): 165.1 ( 11:07:17)
Weight (kg): 49.44 ( 11:07:17)

### [diagnoses]
SNOMED 315642008 (primary)
SNOMED 281794004
SNOMED 442438000

### [disposition]
N/A

### [assessment_and_plan]
Primary: SNOMED 315642008
Secondary: SNOMED 281794004, SNOMED 442438000
Assessment: SNOMED 281794004
Assessment: SNOMED 315642008

--- ORDERS (from progress-note XML) ---
N/A

--- DOCUMENTS (attached to encounter) ---
Document count: 0
N/A

### [orders_(from_progress-note_xml)]
N/A

### problem_list_snomed
Diagnoses are recorded in SNOMED CT and are NOT auto-translated - read each documented condition and assign the specific ICD-10-CM yourself (choose the right laterality/acuity/specificity from the note, then verify the code with kb_lookup_icd10 code=...):
  - SNOMED 315642008 (primary): see note
  - SNOMED 281794004: see note
  - SNOMED 442438000: see note

### vitals
  temp: 98.3
  bp: 111/63
  hr: 142
  rr: 16
  bmi: 18.14
  spo2: 97

### visit_meta
Date of service: 2024-09-15
Facility: CHARTR HEALTH - MIDTOWN CLINIC
Place of service: 20 (Urgent Care)
Rendering provider: RODRIGUEZ,LUIS DO
Visit type: UC - EST
New patient: no
Visit minutes: not documented
Problems addressed: 3

### ordering_provider
Rendering / ordering provider: RODRIGUEZ,LUIS DO (NPI 1962435981). For ordered services (imaging/diagnostics) report this NPI as the ordering/referring provider on the claim (Box 17b).

=== AVAILABLE TOOLS ===
  - read_chart({"section": "progress_note"}): Read EHR chart sections (optionally one section).
  - get_status({}): Get the current case status / stage.
  - kb_lookup_icd10({"code": "J02.0"}): Verify an ICD-10-CM code's official description (code -> description). No clinical-term search and no SNOMED auto-translate - YOU assign the code from the documentation, then confirm it here.
  - kb_lookup_cpt({"code": "87880"}): Verify a CPT/HCPCS code's description (code -> description; drug J/Q codes also return their NDC). No clinical-term search - YOU derive the code from the documented activity, then confirm it here.
  - kb_coding_guidelines({"topic": "icd10"}): Reference coding rules (topic=icd10|em|service_lines|modifiers|medical_necessity|workflow, or omit for all). Rules only - you assign the codes from the chart.
  - kb_lookup_modifier({"modifier": "25"}): Look up a CPT modifier's meaning.
  - kb_lookup_carc({"carc": "CO-197"}): Look up a CARC denial code + remedy.
  - kb_lookup_ncci({"cpt_a": "99213", "cpt_b": "20610"}): Check an NCCI procedure-to-procedure pair.
  - kb_lookup_payer_policy({}): Look up this payer's companion-guide policy.
  - kb_lookup_em_guidelines({"level": "99214"}): Look up E/M level guidelines.
  - portal_login({}): Start payer-portal login (triggers OTP).
  - portal_verify_otp({"code": "000000"}): Verify the portal OTP code.
  - portal_member_search({}): Search the payer portal for the member.
  - portal_download_era({}): Download the latest ERA/EOB (835).
  - check_eligibility({}): Run a 270/271 eligibility check.
  - coordinate_benefits({"primary_payer": "MEDICARE"}): Set the primary payer for COB.
  - review_documentation({}): Coder review of the chart documentation.
  - create_provider_query({"topic": "laterality", "question": "Which knee?"}): Send a clarification query to the provider.
  - resolve_provider_query({"query_id": "q-..."}): Read the provider's query response.
  - capture_charges({}): Aggregate billable charges from the chart.
  - add_charge({"code": "87880"}): Manually add a missed charge.
  - submit_prior_auth({"service_codes": ["70553"]}): Submit a 278 prior-auth request.
  - attach_auth_docs({}): Attach clinical docs to the auth.
  - check_prior_auth({}): Poll the prior-auth status.
  - update_provider_identity({"billing_taxonomy": "261QU0200X"}): Correct billing NPI/taxonomy/TIN.
  - set_diagnoses({"codes": ["J02.0", "R50.9"]}): Set Box 21 ICD-10-CM diagnoses (primary first).
  - set_service_lines({"lines": [{"cpt": "99213", "modifiers": ["25"], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}): Set Box 24 CPT/HCPCS service lines (incl. NDC for drug codes).
  - set_claim_header({"referring_npi": "1999999984", "prior_auth_number": "__certified__"}): Set CMS-1500 header boxes (14 onset, 17/17b referring, 23 prior-auth #, 10 accident, 19 notes).
  - run_scrub({}): Run the pre-submission claim scrub (NCCI/MUE/NDC/referring/etc.).
  - submit_claim({}): Build + submit the 837P (runs 999/277CA/835).
  - post_remittance({}): Post a paid ERA and reconcile.
  - attach_documentation({"document_id": "DOC-..."}): Attach a clinical document (PWK) for appeal/audit.
  - file_appeal({"track": "narrative", "rationale": "..."}): File an appeal (corrected_claim or narrative). Only allowed after all 3 submission attempts are exhausted.
  - respond_to_audit({}): Submit records in response to an audit ADR.
  - rebut_audit({}): Rebut an audit recoupment.
  - write_off({}): Write off the balance and close the case.
  - done({}): Signal the case is fully worked.

reward = clamp(0.50·outcome + 0.35·coding + 0.15·process, 0, 1) × (0.90 + 0.10·efficiency) × first_pass_factor