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Trajectory · Claim #383348 · trial 1

Qwen3-32B (thinking) bedrock

Full agent trajectory — every tool call, replayable step by step.

Reward

1.00

Coding

100%

Tool calls

Final stage

closed_paid

Tool-by-tool trajectory · 19 tool calls

#0 portal_login I need to begin by logging into the payer portal to verify the member's eligibility and benefits (Step 1). This is... ＋

Agent reasoning

I need to begin by logging into the payer portal to verify the member's eligibility and benefits (Step 1). This is critical before proceeding with claim submission to ensure the coverage is active for the date of service. I will start with the portal_login tool to initiate this process.

Args · stage intake · day 0

{}

Result

{"ok": true, "note": "OTP sent to registered device; call portal_verify_otp with code 000000 (sim)"}

#1 check_eligibility I need to verify the patient's eligibility and coverage with BCBS OF NY EMPIRE PPO FS before proceeding. Even though... ＋

Agent reasoning

I need to verify the patient's eligibility and coverage with BCBS OF NY EMPIRE PPO FS before proceeding. Even though the chart indicates active coverage for the day of service, I must confirm it through the 270/271 eligibility check to ensure there are no coverage gaps or COB requirements.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "BCBS OF NY EMPIRE PPO FS", "member_id": "MCCE92AA31", "group": "GRP-BAEE", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#2 read_chart I need to review the full clinical documentation to assess the provider's findings, determine the ICD-10-CM... ＋

Agent reasoning

I need to review the full clinical documentation to assess the provider's findings, determine the ICD-10-CM diagnosis for the documented condition, and derive the appropriate CPT/HCPCS service lines before proceeding. Specifically, a new patient urgent care visit with throat infection symptoms was noted, so I need to ensure that the correct ICD-10-CM code for acute pharyngitis is selected, and the appropriate E/M level (99202-99205) is identified based on time and MDM.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:23:00  |  End Time: 11:38:00  |  Length of Stay: 15 min  |  Reason: Throat hurts bad hard time swollowing  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: sore throat with difficulty swallowing, fever,. chills, , Onset:  gradual, Severity:  mild\n[ORAL CAVITY:] mucosa moist, palate normal\n[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi\ …[truncated]

#3 review_documentation I need to review the full documentation to determine if any clarification is needed regarding the diagnosis or other... ＋

Agent reasoning

I need to review the full documentation to determine if any clarification is needed regarding the diagnosis or other clinical details before proceeding with coding. This will ensure there are no ambiguities in the clinical content that could lead to errors in the claim.

Args · stage documentation · day 0

{}

Result

{"ok": true, "doc_state": "coder-reviewed", "provider_query_needed": false, "findings": []}

#4 capture_charges I need to capture all billable charges from the chart based on the documented activity, such as the E/M visit for a... ＋

Agent reasoning

I need to capture all billable charges from the chart based on the documented activity, such as the E/M visit for a new patient, throat examination with white lesions indicating possible strep, and specimen collection for laboratory testing. The charge feed is silent on codes, so I must derive them from the note.

Args · stage charge_capture · day 0

{}

Result

{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Infectious agent antigen detection, Streptococcus group A (rapid strep) (CLIA-waived rapid test)."}, {"source": "visit", "description": "ESTABLISHED patient office/urgent-care evaluation & management visit; 1 problem(s) addressed; total time: not documented. Read the progress note for history/exam/data ordered/risk and assign the E/M level (CPT) per the 2021 MDM …[truncated]

#5 kb_lookup_icd10 I need to translate the primary SNOMED problem (43878008) to the appropriate ICD-10-CM code. The documentation... ＋

Agent reasoning

I need to translate the primary SNOMED problem (43878008) to the appropriate ICD-10-CM code. The documentation describes a 'sore throat with difficulty swallowing, fever, chills, and white lesions on the tonsils,' which suggests a likely diagnosis of acute tonsillitis or pharyngitis. I will research the proper ICD-10-CM code with correct acuity and specificity.

Args · stage charge_capture · day 0

{"code": "J02.0"}

Result

{"code": "J02.0", "found": true, "description": "Streptococcal pharyngitis", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#6 set_diagnoses The documentation indicates a diagnosis of a sore throat with erythematous posterior pharynx and white lesions on... ＋

Agent reasoning

The documentation indicates a diagnosis of a sore throat with erythematous posterior pharynx and white lesions on the tonsils. The SNOMED code 43878008 should correspond to Streptococcal pharyngitis, which maps to ICD-10-CM code J02.0. I now need to set this as the primary diagnosis on the claim.

Args · stage coding · day 0

{"codes": ["J02.0"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "J02.0"}]}

#7 kb_coding_guidelines Before setting the service lines, I must determine the appropriate CPT code for this urgent care visit. Based on the... ＋

Agent reasoning

Before setting the service lines, I must determine the appropriate CPT code for this urgent care visit. Based on the documentation, this is a new patient (visit type: UC - NEW), and the provider performed a brief assessment and management of acute pharyngitis, with minor supportive treatment (home care advice, fluids, rest, and possible follow-up). I need to apply E/M guidelines and determine the appropriate 9920x code based on MDM, time, and documentation depth before assigning the CPT.

Args · stage coding · day 0

{"topic": "em"}

Result

{"topic": "em", "guidelines": ["Level Evaluation & Management from documented MDM (medical decision making) OR total time on the date of service - not from a term search.", "MDM has three elements (number/complexity of problems, amount/complexity of data reviewed, risk of complications); the level is the 2-of-3 that are met or exceeded.", "Do NOT default to the lowest level. Most urgent-care visits are NOT straightforward (99202/99212): an acute illness/injury that is evaluated, worked up, or tr …[truncated]

#8 kb_coding_guidelines The E/M code must be determined based on MDM criteria or total time. Since the visit was 15 minutes and the note... ＋

Agent reasoning

The E/M code must be determined based on MDM criteria or total time. Since the visit was 15 minutes and the note documents an acute illness with data ordered (labs sent), this likely qualifies for a moderate complexity level (99204). I will look up the E/M coding guidelines specific to urgent-care cases to confirm the appropriate level.

Args · stage coding · day 0

{"topic": "em"}

Result

{"topic": "em", "guidelines": ["Level Evaluation & Management from documented MDM (medical decision making) OR total time on the date of service - not from a term search.", "MDM has three elements (number/complexity of problems, amount/complexity of data reviewed, risk of complications); the level is the 2-of-3 that are met or exceeded.", "Do NOT default to the lowest level. Most urgent-care visits are NOT straightforward (99202/99212): an acute illness/injury that is evaluated, worked up, or tr …[truncated]

#9 kb_lookup_em_guidelines I need to derive the appropriate E/M level for the visit. The documentation mentions an acute issue with throat... ＋

Agent reasoning

I need to derive the appropriate E/M level for the visit. The documentation mentions an acute issue with throat pain, difficulty swallowing, and fever. There are no explicit references to MDM elements, but based on the guidelines, a new patient UC visit with an acute illness evaluation and data reviewed/testing ordered typically meets moderate complexity MDM criteria (e.g., 99204). I must confirm whether this level is accurate in the context before setting the service lines.

Args · stage coding · day 0

{"level": "99204"}

Result

{"code": "99204", "patient": "new", "mdm": "moderate", "summary": "1 chronic w/ exacerbation OR 1 acute w/ systemic; moderate data; moderate risk."}

#10 kb_lookup_em_guidelines I need to derive and verify the billable E/M code for the visit. The documentation suggests a new patient urgent... ＋

Agent reasoning

I need to derive and verify the billable E/M code for the visit. The documentation suggests a new patient urgent care visit with an acute illness involving moderate MDM (symptoms like fever, difficulty swallowing, need for lab testing), which maps to a level of 99203 or higher. I will verify the criteria for 99204 and 99203 to determine the correct E/M level.

Args · stage coding · day 0

{"level": "99203"}

Result

{"code": "99203", "patient": "new", "mdm": "low", "summary": "1 stable chronic OR 2 self-limited; limited data review; low risk."}

#11 kb_lookup_em_guidelines I need to determine the appropriate CPT code for the E/M service based on the documentation. Since the patient is... ＋

Agent reasoning

I need to determine the appropriate CPT code for the E/M service based on the documentation. Since the patient is new (per visit_meta) and the visit duration was 15 minutes, I must assess the MDM level and other factors to choose between 99202 to 99205. I will now look up the E/M guidelines to align the level with the documentation in the note and verify the correct code choice for a new patient urgent care visit.

Args · stage coding · day 0

{"level": "99203"}

Result

{"code": "99203", "patient": "new", "mdm": "low", "summary": "1 stable chronic OR 2 self-limited; limited data review; low risk."}

#12 portal_login The next logical step is to log into the payer portal to access additional claim details and verify eligibility or... ＋

Agent reasoning

The next logical step is to log into the payer portal to access additional claim details and verify eligibility or submission requirements directly within the portal. Logging in first will give the necessary access to perform subsequent steps such as downloading ERA, verifying OTP, and searching for the member.

Args · stage coding · day 0

{}

Result

{"ok": true, "note": "OTP sent to registered device; call portal_verify_otp with code 000000 (sim)"}

#13 set_service_lines The next step is to set the service lines (Box 24), which includes selecting the appropriate CPT/HCPCS code for the... ＋

Agent reasoning

The next step is to set the service lines (Box 24), which includes selecting the appropriate CPT/HCPCS code for the encounter, determining the correct E/M level, and linking it to the diagnosis. The patient's visit was an urgent care encounter for a new patient with a sore throat, difficulty swallowing, and lab work sent for further testing, which points to a moderate complexity of medical decision-making (MDM), and the time was not explicitly detailed but the visit lasted 15 minutes and the documentation supports a 99203 level. I will use the set_service_lines tool to include the E/M code along with a lab service code, assuming lab work was conducted.

Args · stage coding · day 0

{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}

#14 run_scrub I need to ensure that the entire claim is clean before submission, including checking for NCCI bundling, correct... ＋

Agent reasoning

I need to ensure that the entire claim is clean before submission, including checking for NCCI bundling, correct modifiers, accurate diagnosis-linking, and NDC compliance where applicable. Since there are service lines with CPT codes 99203 and 87880, and no NDC entries required for this visit, I should run the pre-submission scrub to identify any potential errors or rejections before transmitting the claim.

Args · stage coding · day 0

{}

Result

{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}

#15 submit_claim I must now proceed with submitting the claim for the first time, as the scrub is clean, eligibility is confirmed,... ＋

Agent reasoning

I must now proceed with submitting the claim for the first time, as the scrub is clean, eligibility is confirmed, all service lines and diagnoses are assigned correctly, and no open queries or denials are present. Submission will generate an 835 ERA/EOB, which I'll then review for payment posting or denial handling.

Args · stage coding · day 0

{}

Result

{"ok": false, "error": "log into the payer portal before submitting (portal_login -> portal_verify_otp)"}

#16 portal_verify_otp I need to complete the payer portal login by verifying the OTP in order to proceed with claim submission. The OTP... ＋

Agent reasoning

I need to complete the payer portal login by verifying the OTP in order to proceed with claim submission. The OTP was already sent, and the next logical step is to verify it using the provided code.

Args · stage coding · day 0

{"code": "000000"}

Result

{"ok": true, "note": "authenticated to payer portal"}

#17 submit_claim The claim is ready for submission. I have verified all eligibility, captured all billable charges, assigned... ＋

Agent reasoning

The claim is ready for submission. I have verified all eligibility, captured all billable charges, assigned appropriate ICD-10-CM and CPT codes, passed the scrub, and authenticated on the payer portal. The only remaining step is to submit the claim for processing.

Args · stage remittance · day 16

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-15c498d716", "status": "paid", "billed_cents": 30014, "allowed_cents": 30014, "paid_cents": 6068, "patient_resp_cents": 0, "contractual_cents": 23946, "claim_control_number": "CCN383348-1", "lines": [{"cpt": "87880", "billed_cents": 5000, "allowed_cents": 5000, "paid_cents": 375, "patient_resp_cents": 0, "contractual_cents": 4625}, {"cpt": "99203", "billed_cents": 25014, "allowed_cents": 25014, "paid_cents": 5693, "patient_resp_cents" …[truncated]

#18 post_remittance The claim has already been submitted and paid successfully. Now, my next step is to post the remittance to finalize... ＋

Agent reasoning

The claim has already been submitted and paid successfully. Now, my next step is to post the remittance to finalize the case and reconcile the patient's financial responsibility, which is $0 in this case. Since the 835 ERA shows 'paid' with no patient responsibility, I will execute the post_remittance step to officially close this claim.

Args · stage closed_paid · day 16

{}

Result

{"ok": true, "posted": true, "note": "ERA posted; case closed paid"}