Claim #403065

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

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: NGUYEN,DAVID
MRN: MRN000403065
Account #: ACC7AEB5231
Date of birth: 1993-12-03
Age: 30
Sex: F
Marital status: Divorced
Preferred language: Spanish
Race: Declined
Ethnicity: Declined
Patient status: established (use 99202-99205 if new, 99212-99215 if established)

### contact
Home address: 7393 ELM ST, NEW YORK, NY 10093
Phone: (212) 393-3293
Preferred pharmacy: WALGREENS #1187 - BROADWAY

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

### insurance_card
Payer: MEDICAID OF NEW YORK FS
Plan: MEDICAID
Member ID: MF71EAF3D0
Group number: GRP-61C7
Subscriber: NGUYEN,DAVID (self)
Relationship to subscriber: self

### care_team
Primary care provider (PCP): LEE,ANNA MD
  NPI: 1437194021
Rendering provider (this visit): RODRIGUEZ,LUIS DO
  NPI: 1962435981
Service facility: CHARTR HEALTH - DOWNTOWN CLINIC

### provider_directory
Rendering provider: RODRIGUEZ,LUIS DO
  NPI: 1962435981
Billing provider: CHARTR HEALTH GROUP
  NPI: 1021883051
  Tax ID (EIN): 13-5983293

### progress_note
### [visit]
Date:   |  Start Time: 16:32:00  |  End Time: 16:47:00  |  Length of Stay: 15 min  |  Reason: congestion + couching/ UTI  |  Visit type: UC - EST
Provider: 

Status: CHK

### [clinical_note_(free_text)]
HPI: pt report here for STD Testing, nasal  congestion, cough and urine frequency  1 week , Onset:  acute, Severity:  moderate, Aggravated:  NONE, Relieved:  NONE 1 week denies moderate increased frequency denies Patient has not taken medication n/a denies
History: Patient presents for STD screening. Denies any genitourinary symptoms. No previous history of STD. No contacts with people with known STD. Some high risk sexual activity (unprotected intercourse) but for the most part uses protection.
[FEMALE GENITOURINARY:] not done , Suprapubic tenderness
[PSYCH:] alert, oriented, cooperative with exam, good eye contact, speech clear
[LYMPH NODES:] no cervical adenopathy, no axillary adenopathy
[BACK:] normal
[PERIPHERAL PULSES:] 2+ throughout
[EXTREMITIES:] no clubbing, cyanosis, or edema
[SKIN:] warm and dry, no suspicious lesions
[NEUROLOGIC:] nonfocal, motor strength normal upper and lower extremities, sensory exam intact
[ABDOMEN:] Soft, nontender, nondistended, no guarding or rigidity, bowel sounds present
[LUNGS:] clear to auscultation bilaterally
[HEART:] regular rate and rhythm, S1, S2 normal, no murmurs
[NECK/THYROID:] neck supple, full range of motion, no cervical lymphadenopathy
[THROAT:] posterior pharynx normal, tonsils without erythema or exudates.
[EARS:] auditory canal clear b/l, TM intact,  light reflex present b/l, no erythema noted
[EYES:] sclera non-icteric, conjunctiva clear
[HEAD:] normocephalic, atraumatic
[GENERAL APPEARANCE:] well developed, well nourished, in no acute distress
Billing: $0 copay, deductible, coinsurance as per RTV, no collection made
McKeever, Yael  04:35:04 PM >
Giordano,Kalani  06:15:29 PM > Added 28 modifier
Gabler,Jaidan  10:23:22 AM > Checked with St. Vincent Medical Center, found that member is active on DOS with effective day ,(Urgent Care) Co-pay = $0, Co-insurance = 0%, Ded./Left=$0/$0(as per Portal)
Family: Unremarkable
PrevMed: The results of your STD panel will be available for pick up in the next 3-5 days.  Please be advised that we do not give these results over the phone.

Drink plenty of fluids and stay hydrated. 
Get plenty of rest. 
If symptoms worsen then go to the ER for further evaluation. 
Follow up with PCP as needed
Social: Unremarkable

### [vitals]
Temperature:  ( 16:47:26)
Blood Pressure:  ( 16:47:26)
Heart Rate:  ( 16:47:26)
Respiratory Rate:  ( 16:47:26)
Height:  ( 16:47:26)
Weight:  ( 16:47:26)
BMI:  ( 16:47:26)
Oxygen Saturation %:  ( 16:47:26)
Height (cm):  ( 16:47:26)
Weight (kg):  ( 16:47:26)

### [diagnoses]
SNOMED 49650001 (primary)
SNOMED 305058001
SNOMED 444451006
SNOMED 309406008
SNOMED 454791000124107
SNOMED 444433005
__CLIN_SNOMED_51887__

### [disposition]
N/A

### [assessment_and_plan]
N/A

--- 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 49650001 (primary): see note
  - SNOMED 305058001: see note
  - SNOMED 444451006: see note
  - SNOMED 309406008: see note
  - SNOMED 454791000124107: see note
  - SNOMED 444433005: see note
  - SNOMED 49727002: see note

### visit_meta
Date of service: 2024-09-15
Facility: CHARTR HEALTH - DOWNTOWN 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: 7

### 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