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Trajectory · Claim #78489 · trial 1

GPT-5.4 openai

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 · 21 tool calls

#0 check_eligibility First I need to satisfy the workflow requirement to verify active coverage before any billing steps. I’m running a... ＋

Agent reasoning

First I need to satisfy the workflow requirement to verify active coverage before any billing steps. I’m running a 270/271 eligibility check to confirm coverage on the date of service and identify any COB indicators or benefit limitations that could affect claim setup.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "member_id": "M1BEF2C8CD", "group": "GRP-0C50", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#1 review_documentation I need a structured coder review of the chart before assigning ICD-10, E/M, or deciding whether any provider query... ＋

Agent reasoning

I need a structured coder review of the chart before assigning ICD-10, E/M, or deciding whether any provider query is needed. This should surface documentation sufficiency, likely billable services, and any missing elements that could affect claim accuracy.

Args · stage documentation · day 0

{}

Result

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

#2 read_chart I need to derive the diagnosis and E/M correctly from the actual chart details, and the progress note has no formal... ＋

Agent reasoning

I need to derive the diagnosis and E/M correctly from the actual chart details, and the progress note has no formal assessment/plan. I’m reopening the chart to inspect all relevant sections together for any overlooked documentation affecting ICD-10 specificity, time/MDM, or additional billable services before setting codes.

Args · stage documentation · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:50:00  |  End Time: 15:05:00  |  Length of Stay: 15 min  |  Reason: pain, ankle  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: pt twisted right ankle approx 1 week ago.  still in pain\n[EXTREMITIES:] Right ankle swelling noted at lateral malleolus; full rom with pain at lateral malleolus on inversion.\n[SKIN:] warm and dry, no suspicious lesions\n[NEUROL …[truncated]

#3 kb_coding_guidelines Before assigning ICD-10 and CPT, I need the coding rules that govern urgent care/professional service selection, E/M... ＋

Agent reasoning

Before assigning ICD-10 and CPT, I need the coding rules that govern urgent care/professional service selection, E/M leveling, and service-line construction so I can avoid a wasted submission. I expect this to confirm whether this visit should be billed as a standard office/urgent care E/M and what documentation thresholds apply.

Args · stage documentation · day 0

{"topic": "workflow"}

Result

{"topic": "workflow", "guidelines": ["Investigate before you commit - a wrong (re)submission burns one of your limited payer adjudications.", "After ANY coding or claim-header edit, the corrected claim is dirty: re-run run_scrub and clear every flag BEFORE submit_claim, or the resubmission is refused.", "On a denial, read the full ERA (portal_download_era), look up the CARC/RARC (kb_lookup_carc), fix ONLY the element that failed, re-scrub, then resubmit - or file_appeal once if the coding alread …[truncated]

#4 capture_charges I need to identify all billable activity before assigning codes, since the charge feed currently has nothing... ＋

Agent reasoning

I need to identify all billable activity before assigning codes, since the charge feed currently has nothing captured and the chart may support at least an urgent care E/M. I expect this to confirm whether there are any additional billable services beyond the visit itself so I can code the claim completely on the first submission.

Args · stage charge_capture · day 0

{}

Result

{"ok": true, "charge_feed": [{"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-or-time guidelines (kb_lookup_em_guidelines).", "activity": "evaluation_and_management"}], "note": "The feed lists clinical activity, not codes - assign each CPT/HCPCS yourself (verify a chosen code with kb_ …[truncated]

#5 kb_coding_guidelines I need the E/M coding rules specific to this visit so I can level the urgent care professional service correctly... ＋

Agent reasoning

I need the E/M coding rules specific to this visit so I can level the urgent care professional service correctly from MDM/time and avoid wasting a submission. I’m checking the E/M guideline framework before selecting the CPT level.

Args · stage charge_capture · 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]

#6 kb_lookup_icd10 I need to verify the exact diagnosis code for the documented problem before setting Box 21. The note supports a... ＋

Agent reasoning

I need to verify the exact diagnosis code for the documented problem before setting Box 21. The note supports a right ankle sprain after twisting injury with pain/swelling at the lateral malleolus, so I’ll confirm the ICD-10-CM description for the likely initial-encounter code before committing diagnoses.

Args · stage charge_capture · day 0

{"code": "S93.401A"}

Result

{"code": "S93.401A", "found": true, "description": "Sprain of unspecified ligament of right ankle, initial encounter", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#7 kb_lookup_em_guidelines I need to verify the E/M leveling rules for a new urgent care visit before assigning the CPT, since this chart has a... ＋

Agent reasoning

I need to verify the E/M leveling rules for a new urgent care visit before assigning the CPT, since this chart has a single acute injury with limited documented data and no procedure orders. This will confirm whether a new-patient office/UC E/M can be supported and at what level from MDM/time.

Args · stage charge_capture · day 0

{"level": "99202"}

Result

{"code": "99202", "patient": "new", "mdm": "straightforward", "summary": "1 self-limited problem; minimal/none data; minimal risk."}

#8 kb_lookup_icd10 I need the official ICD-10 description for the right ankle sprain code already selected from the note before setting... ＋

Agent reasoning

I need the official ICD-10 description for the right ankle sprain code already selected from the note before setting Box 21. This confirms laterality and initial-encounter specificity match the documentation of a twisted right ankle seen for active treatment.

Args · stage charge_capture · day 0

{"code": "S93.401A"}

Result

{"code": "S93.401A", "found": true, "description": "Sprain of unspecified ligament of right ankle, initial encounter", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#9 portal_login The chart and eligibility are already reviewed, and the recommended next step is to log into the payer portal so I... ＋

Agent reasoning

The chart and eligibility are already reviewed, and the recommended next step is to log into the payer portal so I can complete payer-side verification and be ready to obtain remittance/portal details after submission. This advances the workflow without risking a submission before the claim is fully built.

Args · stage charge_capture · day 0

{}

Result

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

#10 portal_verify_otp I already have the OTP prompt, and logging into the payer portal is still an unchecked required step before... ＋

Agent reasoning

I already have the OTP prompt, and logging into the payer portal is still an unchecked required step before finalizing and submitting. I’ll verify the simulated OTP now so I can access portal functions later if needed for claim status or ERA review.

Args · stage charge_capture · day 0

{"code": "000000"}

Result

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

#11 read_chart I need to inspect the chart details directly before final coding, especially to confirm whether any orders/imaging,... ＋

Agent reasoning

I need to inspect the chart details directly before final coding, especially to confirm whether any orders/imaging, documented MDM elements, or additional diagnoses/services were missed beyond the brief summary. This will help me set the most accurate ICD-10 and E/M service line without wasting a submission.

Args · stage charge_capture · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:50:00  |  End Time: 15:05:00  |  Length of Stay: 15 min  |  Reason: pain, ankle  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: pt twisted right ankle approx 1 week ago.  still in pain\n[EXTREMITIES:] Right ankle swelling noted at lateral malleolus; full rom with pain at lateral malleolus on inversion.\n[SKIN:] warm and dry, no suspicious lesions\n[NEUROL …[truncated]

#12 set_diagnoses The chart documents a right ankle twisting injury with persistent pain/swelling one week later, which supports a... ＋

Agent reasoning

The chart documents a right ankle twisting injury with persistent pain/swelling one week later, which supports a right ankle sprain initial encounter diagnosis. I will set the diagnosis now so I can move on to deriving the professional service line and scrubbing the claim.

Args · stage coding · day 0

{"codes": ["S93.401A"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "S93.401A"}]}

#13 kb_coding_guidelines I need the official coding rules for urgent care/professional service-line selection before setting Box 24, because... ＋

Agent reasoning

I need the official coding rules for urgent care/professional service-line selection before setting Box 24, because the instructions warn that some urgent care encounters may use a case-rate/global code family rather than a standard office E/M. This will tell me whether to bill a new-patient E/M like 99202 or an urgent-care-specific code for this payer/workflow.

Args · stage coding · day 0

{"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]

#14 kb_coding_guidelines I need to verify the exact E/M leveling rules for a new patient urgent care visit before assigning the service line,... ＋

Agent reasoning

I need to verify the exact E/M leveling rules for a new patient urgent care visit before assigning the service line, since the chart documents a single acute ankle injury with limited data and no procedures. This should confirm whether the documented MDM supports 99202 versus a higher new-patient level so we avoid wasting a submission.

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]

#15 set_service_lines The chart supports only an office/urgent-care E/M with no separately billable procedures, supplies, drugs, labs, or... ＋

Agent reasoning

The chart supports only an office/urgent-care E/M with no separately billable procedures, supplies, drugs, labs, or imaging documented. This is a new patient with an acute uncomplicated right ankle sprain, no data reviewed/ordered, and low risk, so I will set a single 99203 line with POS 20 linked to the ankle-sprain diagnosis.

Args · stage coding · day 0

{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#16 run_scrub I need to clear the remaining pre-submission issue before using one of the limited claim submissions. Running the... ＋

Agent reasoning

I need to clear the remaining pre-submission issue before using one of the limited claim submissions. Running the scrub now will identify exactly what header, coding, modifier, or payer-edit elements still need correction so I can fix them before transmitting.

Args · stage coding · day 0

{}

Result

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

#17 kb_lookup_cpt The claim is already coded and scrub-clean, but before spending a submission attempt I want to confirm the official... ＋

Agent reasoning

The claim is already coded and scrub-clean, but before spending a submission attempt I want to confirm the official CPT descriptor for the chosen E/M level against the documented new urgent-care visit. This verifies that 99203 is the correct professional service to submit for this chart.

Args · stage coding · day 0

{"code": "99203"}

Result

{"code": "99203", "found": true, "desc": "Office/outpatient E/M, NEW patient, low MDM", "category": "em_new", "patient": "new", "mdm": "low"}

#18 kb_lookup_payer_policy The claim is already coded and scrub-clean, but before spending a submission I need to confirm this payer’s... ＋

Agent reasoning

The claim is already coded and scrub-clean, but before spending a submission I need to confirm this payer’s professional billing requirements for urgent care and whether any Oxford-specific companion-guide detail could affect the E/M, taxonomy, or header fields. I expect to verify there is no payer-specific requirement that would make 99203 in POS 20 deny despite passing the generic scrub.

Args · stage coding · day 0

{}

Result

{"payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "payer_class": "COMMERCIAL", "policy": {"timely_filing_days": 90, "appeal_window_days": 180, "common_denials": ["CO-167", "CO-A1", "CO-22"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 267, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 21, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "95227"}}

#19 submit_claim The claim is already coded and scrub-clean, and there are no unaddressed auth, COB, or documentation issues for this... ＋

Agent reasoning

The claim is already coded and scrub-clean, and there are no unaddressed auth, COB, or documentation issues for this visit. The next necessary step is to submit the initial 837P and see whether it clears 999/277CA and adjudicates without denial.

Args · stage remittance · day 23

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-29917c0b40", "status": "paid", "billed_cents": 15100, "allowed_cents": 15000, "paid_cents": 13000, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN78489-1", "lines": [{"cpt": "99203", "billed_cents": 15100, "allowed_cents": 15000, "paid_cents": 13000, "patient_resp_cents": 0, "contractual_cents": 0}], "carcs": [], "rarcs": [], "posted": false, "transaction": "835"}, "era_text": "835 ERA / EOB   CCN=CCN7848 …[truncated]

#20 post_remittance The claim is already accepted and paid, and the checklist shows the only remaining required step is remittance... ＋

Agent reasoning

The claim is already accepted and paid, and the checklist shows the only remaining required step is remittance posting. I will post the paid ERA now to reconcile the payment and patient responsibility so the case can be closed cleanly.

Args · stage closed_paid · day 23

{}

Result

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