Claim #56095

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: PATEL,LATOYA
MRN: MRN000056095
Account #: ACC5E080A9C
Date of birth: 1996-03-01
Age: 28
Sex: M
Marital status: Widowed
Preferred language: Spanish
Race: Other
Ethnicity: Hispanic or Latino
Patient status: new (use 99202-99205 if new, 99212-99215 if established)

### contact
Home address: 8166 PARK BLVD, NEW YORK, NY 10066
Phone: (212) 466-1066
Preferred pharmacy: WALGREENS #1187 - BROADWAY

### allergies
Drug allergies: Penicillin - rash (low severity)
Environmental: not on file
(reference only - not a billable item)

### insurance_card
Payer: HEALTHFIRST OF NEW YORK GR
Plan: MEDICAID
Member ID: MD9134E2A6
Group number: GRP-F852
Subscriber: PATEL,LATOYA (self)
Relationship to subscriber: self

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

### provider_directory
Rendering provider: LEE,ANNA MD
  NPI: 1437194021
Billing provider: CHARTR HEALTH GROUP
  NPI: 1493447462
  Tax ID (EIN): 66-1921066

### progress_note
### [visit]
Date:   |  Start Time: 20:03:00  |  End Time: 20:18:00  |  Length of Stay: 15 min  |  Reason: abdominal pain  |  Visit type: UC - NEW
Provider: 

Status: CHK

### [clinical_note_(free_text)]
History: 28 yo male c/o abdominal pain x 1 day; Endorses N and 5 episodes of D. Denies vomiting, or cold sx.
[MUSCULOSKELETAL:] normal, no swelling or deformity
[SKIN:] no rashes, normal, good turgor, warm and dry
[ABDOMEN:] bowel sounds present, no guarding, no rebounding, negative Murphy's sign, negative psoas, negative obturator, negative rovsing's.
[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi
[HEART:] regular rate and rhythm
[NECK/THYROID:] neck supple
[EYES:] normal, pupils equal, round, reactive to light
[HEAD:] normocephalic, atraumatic
[GENERAL APPEARANCE:] well nourished, well developed, in no acute distress,
Billing: Avery,Alphonso  17:20:38 PM > No changes.
Serrano,Eloy   3:40:23 PM > Checked with HealthFirst , patient is active on DOS with effective date from  , Co-pay $0 , Co-Insurance 0% and Deductible $0/$0.
PrevMed: Gastroenteritis is an illness that may cause nausea, vomiting, and diarrhea. It is sometimes called "stomach flu." It can be caused by bacteria or a virus.

You will probably begin to feel better in 1 to 2 days. In the meantime, get plenty of rest and make sure you do not become dehydrated. Dehydration occurs when your body loses too much fluid.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.

How can you care for yourself at home?
If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.
Drink plenty of fluids to prevent dehydration, enough so that your urine is light yellow or clear like water. Choose water and other caffeine-free clear liquids until you feel better. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase your fluid intake.
Drink fluids slowly, in frequent, small amounts, because drinking too much too fast can cause vomiting.
Begin eating mild foods, such as dry toast, yogurt, applesauce, bananas, and rice. Avoid spicy, hot, or high-fat foods, and do not drink alcohol or caffeine for a day or two. Do not drink milk or eat ice cream until you are feeling better.
How to prevent gastroenteritis
Keep hot foods hot and cold foods cold.
Do not eat meats, dressings, salads, or other foods that have been kept at room temperature for more than 2 hours.
Use a thermometer to check your refrigerator. It should be between 34??F and 40??F.
Defrost meats in the refrigerator or microwave, not on the kitchen counter.
Keep your hands and your kitchen clean. Wash your hands, cutting boards, and countertops with hot soapy water frequently.
Cook meat until it is well done.
Do not eat raw eggs or uncooked sauces made with raw eggs.
Do not take chances. If food looks or tastes spoiled, throw it out.

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 in 2-3 days

BRAT: Is an acronym for Bananas, Rice, Apples and Toast. 
The diet does not need to consist of only these foods, and depending on the severity of your nausea, vomiting, or diarrhea, you may need to introduce solids back into your diet over the course of a few days.

Latrina Diet:
First six hours: In the immediate six or so hours after vomiting has stopped, it is best to give your stomach a rest. Following a period of one to two hours, suck on a hard candy or popsicle (no chewing). Then progress to ice chips or sips of water if nausea persists.
First 24 hours: (Day One) Gradually add clear liquids if the vomiting has ceased. Beginning with a sip or two every ten minutes is a good way to start. Suggestions include water, apple juice, flat soda, weak tea, jello (in liquid or gelatin form), broth or bouillon (clear based from non-greasy soup). If symptoms of nausea or vomiting return, begin the process again, taking nothing by mouth for an hour or so.
Day Two: Begin to add bland foods like bananas, rice, applesauce, crackers, cooked cereals (Farina, Cream of Wheat), toast and jelly.
Day Three: Progress to a "regular" diet by adding such things as soft cooked eggs, sherbet, stewed fruits, cooked vegetables, white meat of chicken or turkey.

### [vitals]
Temperature:  ( 20:15:50)
Blood Pressure:  ( 20:15:50)
Heart Rate:  ( 20:15:50)
Respiratory Rate:  ( 20:15:50)
Height:  ( 20:15:50)
Weight:  ( 20:15:50)
BMI:  ( 20:15:50)
Height (cm):  ( 20:15:50)
Weight (kg):  ( 20:15:50)

### [diagnoses]
SNOMED 25374005 (primary)

### [disposition]
N/A

### [assessment_and_plan]
N/A

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

--- DOCUMENTS (attached to encounter) ---
Document count: 1
  docID 83421  |  type: Speciality Forms  |  name: Thatcher-C  20:16:25  |  description: EMR Form  |  scanDate:  20:16:25

### [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 25374005 (primary): see note

### visit_meta
Date of service: 2024-09-15
Facility: CHARTR HEALTH - RIVERSIDE FAMILY MEDICINE
Place of service: 20 (Urgent Care)
Rendering provider: LEE,ANNA MD
Visit type: UC - NEW
New patient: yes
Visit minutes: not documented
Problems addressed: 1

### ordering_provider
Rendering / ordering provider: LEE,ANNA MD (NPI 1437194021). 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