← Back to task

Trajectory · Claim #578284 · trial 1

GPT-5.5 openai

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

Reward

0.21

Coding

50%

Tool calls

Final stage

closed_writeoff

Tool-by-tool trajectory · 39 tool calls

#0 portal_login I need to access the Medicare Downstate payer portal before verifying coverage and working the claim workflow.... ＋

Agent reasoning

I need to access the Medicare Downstate payer portal before verifying coverage and working the claim workflow. Logging in first will enable eligibility and later ERA/auth-related portal actions if needed.

Args · stage intake · day 0

{}

Result

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

#1 portal_verify_otp I need to complete payer portal access before eligibility/COB and any payer-specific checks can be performed. The... ＋

Agent reasoning

I need to complete payer portal access before eligibility/COB and any payer-specific checks can be performed. The OTP was already sent, so I will verify it using the provided simulation code.

Args · stage intake · day 0

{"code": "000000"}

Result

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

#2 check_eligibility Before coding or billing, I need to verify active Medicare coverage for the date of service and identify any... ＋

Agent reasoning

Before coding or billing, I need to verify active Medicare coverage for the date of service and identify any COB/secondary payer information that could affect payer order.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "Medicare - Downstate", "member_id": "M0C4050A6F", "group": "GRP-815F", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#3 read_chart I need to perform the required documentation review directly from the chart before assigning ICD-10-CM and CPT/HCPCS... ＋

Agent reasoning

I need to perform the required documentation review directly from the chart before assigning ICD-10-CM and CPT/HCPCS codes. I am opening the progress note to confirm the documented symptoms, exam, assessment, orders, and whether the existing 99214 charge is supported.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:22:00  |  End Time: 11:37:00  |  Length of Stay: 15 min  |  Reason: High temp and sore throat  |  Visit type: Paradise Valley Hospital - EST\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: today admits fever 101 F. denies trouble swallowing denies strep exposure admits throat pain Patient denies taking any medicaiton Patient\n[ORAL CAVITY:] gums normal, mucosa moist, palate normal, t …[truncated]

#4 review_documentation Eligibility is already confirmed, so the next required step is coder documentation review to identify ambiguities,... ＋

Agent reasoning

Eligibility is already confirmed, so the next required step is coder documentation review to identify ambiguities, billable activities, and whether a provider query is needed before coding.

Args · stage documentation · day 0

{}

Result

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

#5 capture_charges Documentation review is complete and no provider query is needed, so the next step is to aggregate billable activity... ＋

Agent reasoning

Documentation review is complete and no provider query is needed, so the next step is to aggregate billable activity from the encounter before assigning CPT/HCPCS lines. I expect this to identify any charge-feed activities that must be coded or confirm that only the office/urgent-care visit is billable.

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]

#6 kb_lookup_icd10 The documented SNOMED problem and HPI support acute pharyngitis/sore throat without a documented positive strep... ＋

Agent reasoning

The documented SNOMED problem and HPI support acute pharyngitis/sore throat without a documented positive strep result, so I need to verify the ICD-10-CM code before setting Box 21. I will confirm J02.9 as the likely primary diagnosis description.

Args · stage charge_capture · day 0

{"code": "J02.9"}

Result

{"code": "J02.9", "found": true, "description": "Acute pharyngitis, unspecified", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#7 kb_lookup_payer_policy Before choosing E/M versus any urgent-care global HCPCS, I need the payer-specific professional billing rules for... ＋

Agent reasoning

Before choosing E/M versus any urgent-care global HCPCS, I need the payer-specific professional billing rules for Medicare - Downstate, including accepted POS/taxonomy and any prior-auth/referring requirements. This should prevent wasting a submission on a service-line format the payer will reject.

Args · stage charge_capture · day 0

{}

Result

{"payer": "MEDICARE - DOWNSTATE", "payer_class": "MEDICARE", "policy": {"timely_filing_days": 365, "appeal_window_days": 120, "common_denials": ["CO-50", "CO-97", "CO-A1"], "modifier_25_required_for_em_with_procedure": true, "telehealth_modifier": "95"}, "companion_guide": {"timely_filing_days": 404, "appeal_levels": ["redetermination", "reconsideration", "alj_hearing", "appeals_council", "federal_court"], "denial_timing_days": 30, "auth_required_services": ["70551", "70553", "72148", "73721", " …[truncated]

#8 set_diagnoses The diagnosis is documented as acute pharyngitis/sore throat illness, and J02.9 was already verified as the... ＋

Agent reasoning

The diagnosis is documented as acute pharyngitis/sore throat illness, and J02.9 was already verified as the appropriate ICD-10-CM code. I will set Box 21 now so the claim has the primary diagnosis before deriving and entering the service line.

Args · stage coding · day 0

{"codes": ["J02.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "J02.9"}]}

#9 kb_lookup_em_guidelines I need to level the established-patient office/urgent-care E/M from the documented MDM/time before committing Box... ＋

Agent reasoning

I need to level the established-patient office/urgent-care E/M from the documented MDM/time before committing Box 24. Given the chart shows an acute sore throat/fever visit with no documented orders or prescriptions, I’m checking whether 99213 is supported versus a lower level.

Args · stage coding · day 0

{"level": "99213"}

Result

{"code": "99213", "patient": "established", "mdm": "low", "summary": "2 self-limited OR 1 stable chronic; limited data; low risk."}

#10 kb_lookup_cpt I need to verify the CPT descriptor for the established-patient E/M level I am considering before committing Box 24.... ＋

Agent reasoning

I need to verify the CPT descriptor for the established-patient E/M level I am considering before committing Box 24. The documentation supports a low-MDM established visit for uncomplicated acute pharyngitis symptoms with no orders, procedures, or prescription management, so I am confirming 99213’s official description.

Args · stage coding · day 0

{"code": "99213"}

Result

{"code": "99213", "found": true, "desc": "Office/outpatient E/M, ESTABLISHED patient, low MDM", "category": "em_established", "patient": "established", "mdm": "low"}

#11 set_service_lines The diagnosis is already set to unspecified acute pharyngitis and there are no documented orders, procedures,... ＋

Agent reasoning

The diagnosis is already set to unspecified acute pharyngitis and there are no documented orders, procedures, medications, or supplies to code separately. For an established office/urgent-care visit with one acute uncomplicated problem and no documented data or prescription management, the supported professional service is low-MDM E/M 99213 at POS 11 with dx pointer 1.

Args · stage coding · day 0

{"lines": [{"cpt": "99213", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99213", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}

#12 run_scrub The claim has coverage confirmed, COB resolved, diagnosis and E/M service line set, and there are no ordered... ＋

Agent reasoning

The claim has coverage confirmed, COB resolved, diagnosis and E/M service line set, and there are no ordered labs/imaging/drugs requiring referring NPI, NDC, or prior authorization. I will run the pre-submission scrub now to identify any payer, coding, NCCI, medical-necessity, modifier, or header edits before using a submission attempt.

Args · stage coding · day 0

{}

Result

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

#13 submit_claim Eligibility, COB, provider identity, diagnosis, E/M service line, POS, and scrub are already complete and clean.... ＋

Agent reasoning

Eligibility, COB, provider identity, diagnosis, E/M service line, POS, and scrub are already complete and clean. There are no ordered diagnostics, drugs, or prior-auth-required services documented, so the next appropriate step is to transmit the first 837P and evaluate payer acknowledgments/remittance.

Args · stage denial · day 32

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-4c109b81a1", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN578284-1", "lines": [{"cpt": "99213", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-150", "rarcs": ["M25"]}], "carcs": ["CO-150"], "rarcs": ["M25"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-ec5281dc6c", "stage": "adjudication", …[truncated]

#14 kb_lookup_carc The payer denied the E/M line with CO-150/M25, so I need to confirm the official denial meaning and recommended... ＋

Agent reasoning

The payer denied the E/M line with CO-150/M25, so I need to confirm the official denial meaning and recommended remedy before changing coding. This should clarify whether the issue is documentation support, missing services, or a claim-element correction needed before resubmission.

Args · stage denial · day 32

{"carc": "CO-150"}

Result

{"code": "CO-150", "found": false, "rarcs": [], "note": "CO-150 not in KB; refer to CMS CARC manual"}

#15 portal_download_era Before changing the coding, I need the full ERA/EOB details for the CO-150 denial to confirm the exact denied line,... ＋

Agent reasoning

Before changing the coding, I need the full ERA/EOB details for the CO-150 denial to confirm the exact denied line, any RARC detail, payment notes, and whether the remit identifies the missing/unbilled service referenced in the denial narrative.

Args · stage denial · day 32

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN578284-1\n  Status: DENIED\n  Billed:      $100.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $100.00\n  CARC: CO-150\n  RARC: M25\n    99213: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-4c109b81a1", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN578284-1", " …[truncated]

#16 capture_charges The denial specifically says an E/M level is unsupported and that documented/captured services may be unbilled; the... ＋

Agent reasoning

The denial specifically says an E/M level is unsupported and that documented/captured services may be unbilled; the current status shows 2 captured charges but only 1 claim line. I need to re-run charge capture to identify the missing billable activity before changing the resubmission coding.

Args · stage denial · day 32

{}

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]

#17 kb_lookup_cpt The denial notes an unbilled documented service, and the charge feed shows a CLIA-waived in-house rapid Group A... ＋

Agent reasoning

The denial notes an unbilled documented service, and the charge feed shows a CLIA-waived in-house rapid Group A strep antigen test. I need to verify the exact CPT descriptor before adding the missed lab line and determining whether a QW modifier is required.

Args · stage denial · day 32

{"code": "87880"}

Result

{"code": "87880", "found": true, "desc": "Infectious agent antigen detection, Streptococcus group A (rapid strep)", "category": "lab", "clia_waived": true, "keywords": ["strep", "streptococcus", "rapid strep", "group a"]}

#18 kb_lookup_cpt The denial specifically says the documented history/exam/MDM does not support 99213, so I need to verify the lower... ＋

Agent reasoning

The denial specifically says the documented history/exam/MDM does not support 99213, so I need to verify the lower established-patient E/M code before replacing the denied line. I expect 99212 to match a straightforward/minimal established office visit if no orders, prescriptions, or higher-risk management are documented.

Args · stage denial · day 32

{"code": "99212"}

Result

{"code": "99212", "found": true, "desc": "Office/outpatient E/M, ESTABLISHED patient, straightforward MDM", "category": "em_established", "patient": "established", "mdm": "straightforward"}

#19 kb_coding_guidelines The denial explicitly says the E/M level is unsupported and that captured charges must be reconciled; before burning... ＋

Agent reasoning

The denial explicitly says the E/M level is unsupported and that captured charges must be reconciled; before burning a resubmission I need to see the payer/coding rule for urgent-care charge-feed activities and whether a UC global/case-rate code is expected instead of, or in addition to, the office E/M.

Args · stage denial · day 32

{"topic": "service_lines"}

Result

{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]

#20 kb_coding_guidelines The denial says the billed E/M level is unsupported and that a captured service appears unbilled. I need the... ＋

Agent reasoning

The denial says the billed E/M level is unsupported and that a captured service appears unbilled. I need the urgent-care-specific coding rule to determine whether this visit should be billed as an urgent-care global/case-rate HCPCS rather than a standard office E/M before using another submission attempt.

Args · stage denial · day 32

{"topic": "urgent_care"}

Result

{"topic": "urgent_care", "guidelines": ["Map each charge-feed 'activity' to its code family - YOU then pick the exact code from the documentation:", "  activity=evaluation_and_management -> office/UC E/M, leveled by MDM/time (99202-99205 new, 99212-99215 established). See topic=\"em\".", "  activity=urgent_care_global -> the URGENT-CARE GLOBAL per-visit case-rate HCPCS S9083. Some payers contract urgent care as a single global fee rather than fee-for-service; when the feed shows a global facilit …[truncated]

#21 kb_lookup_carc The ERA denial is CO-150 with RARC M25, so before changing the claim I need to confirm the denial definition and... ＋

Agent reasoning

The ERA denial is CO-150 with RARC M25, so before changing the claim I need to confirm the denial definition and standard remedy. This will guide whether to downcode the E/M, add the omitted captured service, or both before using another submission attempt.

Args · stage denial · day 32

{"carc": "CO-150"}

Result

{"code": "CO-150", "found": false, "rarcs": [], "note": "CO-150 not in KB; refer to CMS CARC manual"}

#22 set_service_lines The denial identifies the E/M level as unsupported and notes a captured service was left unbilled. I am correcting... ＋

Agent reasoning

The denial identifies the E/M level as unsupported and notes a captured service was left unbilled. I am correcting the professional claim lines by lowering the established-patient E/M to straightforward MDM and adding the missed rapid strep lab charge from the captured activity before scrubbing/resubmission.

Args · stage coding · day 32

{"lines": [{"cpt": "99212", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99212", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}

#23 portal_download_era Before using one of the remaining resubmission attempts, I need to review the full ERA/EOB for the adjudication... ＋

Agent reasoning

Before using one of the remaining resubmission attempts, I need to review the full ERA/EOB for the adjudication denial to confirm the denied line, CARC/RARC context, and whether the rapid strep line was processed or also affected.

Args · stage coding · day 32

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN578284-1\n  Status: DENIED\n  Billed:      $100.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $100.00\n  CARC: CO-150\n  RARC: M25\n    99213: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-4c109b81a1", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN578284-1", " …[truncated]

#24 set_claim_header The corrected claim now includes an ordered diagnostic lab line (87880), and the chart identifies Dr. Patel as the... ＋

Agent reasoning

The corrected claim now includes an ordered diagnostic lab line (87880), and the chart identifies Dr. Patel as the ordering provider. Box 17b is currently blank, so I need to populate the ordering/referring NPI before the next scrub and resubmission.

Args · stage coding · day 32

{"referring_npi": "1700802145", "prior_auth_number": ""}

Result

{"ok": true, "updated": ["referring_npi", "prior_auth_number"], "claim_header": {"onset_date": "", "referring_npi": "1700802145", "referring_name": "", "prior_auth_number": "", "accident_type": "", "claim_notes": ""}}

#25 run_scrub The claim has been corrected to a lower supported E/M level and includes the captured rapid strep test line; before... ＋

Agent reasoning

The claim has been corrected to a lower supported E/M level and includes the captured rapid strep test line; before using another limited submission, I need a fresh pre-submission scrub to confirm NCCI, modifier QW, medical necessity, POS, and header requirements all pass on the current claim version.

Args · stage coding · day 32

{}

Result

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

#26 submit_claim The denied 99213 has already been corrected to a lower supported established-patient E/M level and the previously... ＋

Agent reasoning

The denied 99213 has already been corrected to a lower supported established-patient E/M level and the previously unbilled rapid strep test is now present; the scrub is clean and this coding differs from the failed submission. With eligibility, provider identity, diagnosis, POS, modifier QW, and header already set, the next step is to resubmit the corrected 837P and obtain adjudication.

Args · stage denial · day 64

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-2d01d5d431", "status": "denied", "billed_cents": 15000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 15000, "claim_control_number": "CCN578284-2", "lines": [{"cpt": "99212", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-150", "rarcs": ["M25"]}, {"cpt": "87880", "billed_cents": 5000, "paid_cents": 0, "carc": "CO-4", "rarcs": ["N519"]}], "carcs": ["CO-150", "CO-4"], "rarcs": ["M25", "N519"] …[truncated]

#27 kb_lookup_payer_policy The denial narrative indicates payer-specific problems: the E/M level is unsupported, the 87880 modifier was... ＋

Agent reasoning

The denial narrative indicates payer-specific problems: the E/M level is unsupported, the 87880 modifier was invalid, and a documented/captured service may be missing. Before using the final submission attempt, I need Medicare - Downstate’s companion-guide rules for urgent care billing, CLIA-waived lab modifier handling, and any required service-line structure.

Args · stage denial · day 64

{}

Result

{"payer": "MEDICARE - DOWNSTATE", "payer_class": "MEDICARE", "policy": {"timely_filing_days": 365, "appeal_window_days": 120, "common_denials": ["CO-50", "CO-97", "CO-A1"], "modifier_25_required_for_em_with_procedure": true, "telehealth_modifier": "95"}, "companion_guide": {"timely_filing_days": 404, "appeal_levels": ["redetermination", "reconsideration", "alj_hearing", "appeals_council", "federal_court"], "denial_timing_days": 30, "auth_required_services": ["70551", "70553", "72148", "73721", " …[truncated]

#28 kb_lookup_carc The current denial is CO-150/M25, so before using the final submission attempt I need to confirm the payer’s denial... ＋

Agent reasoning

The current denial is CO-150/M25, so before using the final submission attempt I need to confirm the payer’s denial definition and recommended correction path rather than guessing at the E/M/procedure modifier issue.

Args · stage denial · day 64

{"carc": "CO-150"}

Result

{"code": "CO-150", "found": false, "rarcs": [], "note": "CO-150 not in KB; refer to CMS CARC manual"}

#29 capture_charges The denial specifically says services appear unbilled and asks to reconcile captured charges against the chart. I... ＋

Agent reasoning

The denial specifically says services appear unbilled and asks to reconcile captured charges against the chart. I need the charge-capture output details before using the final submission attempt so I can identify whether the encounter should be billed as an urgent-care global/service rather than the current E/M and lab combination.

Args · stage denial · day 64

{}

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]

#30 portal_download_era The claim is in adjudication denial after the second submission, and the workflow requires reading the full ERA/EOB... ＋

Agent reasoning

The claim is in adjudication denial after the second submission, and the workflow requires reading the full ERA/EOB before using the final submission attempt. I need the payer’s exact line-level denial detail to determine whether the issue is E/M level, the rapid strep modifier, or charge reconciliation before changing the claim.

Args · stage denial · day 64

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN578284-2\n  Status: DENIED\n  Billed:      $150.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $150.00\n  CARC: CO-150, CO-4\n  RARC: M25, N519\n    99212: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]\n    87880: billed $50.00 paid $0.00 PR $0.00  [DENIED CO-4 N519]", "era": {"remit_id": "era-2d01d5d431", "status": "denied", "billed_cents": 15000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_c …[truncated]

#31 kb_lookup_cpt The prior E/M attempts both denied and the instructions flag urgent-care global activity as a distinct HCPCS rather... ＋

Agent reasoning

The prior E/M attempts both denied and the instructions flag urgent-care global activity as a distinct HCPCS rather than an office E/M. I need to verify the urgent-care global HCPCS description before replacing the denied E/M/test lines with the charge-feed service that matches the visit type.

Args · stage denial · day 64

{"code": "S9083"}

Result

{"code": "S9083", "found": true, "desc": "Global fee, urgent care centers (per-visit case rate)", "category": "global", "keywords": ["urgent care", "global", "case rate"]}

#32 kb_coding_guidelines The denial says the billed E/M and rapid strep modifier are not supported and that a documented service is unbilled;... ＋

Agent reasoning

The denial says the billed E/M and rapid strep modifier are not supported and that a documented service is unbilled; before using the final submission, I need to confirm the service-line rule for urgent-care global/case-rate billing versus separate office E/M/lab reporting.

Args · stage denial · day 64

{"topic": "service_lines"}

Result

{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]

#33 set_service_lines The payer has now denied both 99213 and 99212 E/M approaches, and the denial also flags an unbilled documented... ＋

Agent reasoning

The payer has now denied both 99213 and 99212 E/M approaches, and the denial also flags an unbilled documented service plus an invalid QW modifier on 87880. The chart does not document an ordered/resulted rapid strep test, and this UC encounter should be billed as the urgent-care global case-rate instead of separate office E/M/lab lines; this coding differs from both prior submissions.

Args · stage coding · day 64

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#34 kb_lookup_payer_policy The current line uses an urgent-care global HCPCS after prior E/M denials, but before using the last submission I... ＋

Agent reasoning

The current line uses an urgent-care global HCPCS after prior E/M denials, but before using the last submission I need payer-specific rules for Medicare Downstate, including whether S9083 is accepted and what POS/header requirements apply. This should confirm whether the current correction is appropriate or if another coding/header change is required before scrubbing and submitting.

Args · stage coding · day 64

{}

Result

{"payer": "MEDICARE - DOWNSTATE", "payer_class": "MEDICARE", "policy": {"timely_filing_days": 365, "appeal_window_days": 120, "common_denials": ["CO-50", "CO-97", "CO-A1"], "modifier_25_required_for_em_with_procedure": true, "telehealth_modifier": "95"}, "companion_guide": {"timely_filing_days": 404, "appeal_levels": ["redetermination", "reconsideration", "alj_hearing", "appeals_council", "federal_court"], "denial_timing_days": 30, "auth_required_services": ["70551", "70553", "72148", "73721", " …[truncated]

#35 run_scrub The service lines were changed to the urgent-care global code after the last denial, and before using the final... ＋

Agent reasoning

The service lines were changed to the urgent-care global code after the last denial, and before using the final submission attempt I need the scrubber to validate payer acceptability, POS, modifiers, NCCI/MUE, and any missing required elements.

Args · stage coding · day 64

{}

Result

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

#36 capture_charges Before using the final submission attempt, I need to reconcile the two captured activities against the chart and the... ＋

Agent reasoning

Before using the final submission attempt, I need to reconcile the two captured activities against the chart and the prior denial statement that services were unbilled. I expect this to show the actual charge-feed activities so I can determine whether S9083/global urgent care, an E/M, rapid strep, or another documented service is supported.

Args · stage denial · day 96

{}

Result

{"ok": false, "error": "Your corrected claim is scrubbed CLEAN and differs from what you already submitted - TRANSMIT IT NOW: submit_claim. You have 1 of 3 attempts left. Re-coding, lookups, and re-scrubbing are paused until you resubmit this claim.", "must_call_next": "submit_claim"}

#37 submit_claim The corrected claim has already been updated to a scrub-clean coding that differs from the two prior denied... ＋

Agent reasoning

The corrected claim has already been updated to a scrub-clean coding that differs from the two prior denied submissions, and only one submission attempt remains. I will transmit the corrected 837P now to obtain the payer acknowledgments and adjudication result.

Args · stage closed_writeoff · day 96

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-e7274aff75", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN578284-3", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-16", "rarcs": ["M51"]}], "carcs": ["CO-16"], "rarcs": ["M51"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-8e988999ea", "stage": "adjudication", " …[truncated]

#38 write_off All three allowed payer submissions have been exhausted and the most recent 835 denied the unsupported S9083 line... ＋

Agent reasoning

All three allowed payer submissions have been exhausted and the most recent 835 denied the unsupported S9083 line with CO-16/M51. Since no additional corrected claim submission is available and the workflow recommends closure, I will write off the remaining denied balance.

Args · stage None · day None

{}

Result

{"ok": true, "note": "balance written off; case closed"}