← Back to task

Trajectory · Claim #78489 · trial 3

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 · 23 tool calls

#0 check_eligibility First I need to satisfy the required coverage verification step before coding or submitting anything. I'll run a... ＋

Agent reasoning

First I need to satisfy the required coverage verification step before coding or submitting anything. I'll run a 270/271 eligibility check to confirm active Oxford Freedom coverage on the date of service and look for any COB indicators.

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 formal coder review of the chart to identify documentation gaps, confirm what services are actually... ＋

Agent reasoning

I need a formal coder review of the chart to identify documentation gaps, confirm what services are actually supported, and determine whether a provider query is needed before coding. This will reduce submission risk given the limited resubmission budget.

Args · stage documentation · day 0

{}

Result

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

#2 kb_coding_guidelines I need to confirm the coding rules that apply here before assigning ICD-10 and the E/M level, especially whether... ＋

Agent reasoning

I need to confirm the coding rules that apply here before assigning ICD-10 and the E/M level, especially whether this urgent care encounter should be billed as a standard office/OP E/M or a UC case-rate and how to level it from the documented MDM/time. This will reduce submission risk before I set diagnoses and service lines.

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]

#3 read_chart I need to inspect the full encounter details directly in the chart before assigning ICD-10 and E/M, because the... ＋

Agent reasoning

I need to inspect the full encounter details directly in the chart before assigning ICD-10 and E/M, because the current summary shows a possible ambiguity around the documented diagnosis and whether any orders or treatment were actually performed. Re-reading the progress note will confirm laterality, injury context, and whether there are any additional billable services beyond the urgent care visit.

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]

#4 kb_coding_guidelines I need the coding rules specific to professional urgent care billing and E/M/service-line construction before... ＋

Agent reasoning

I need the coding rules specific to professional urgent care billing and E/M/service-line construction before selecting CPTs, because the chart warns that some urgent care visits may use a global case-rate rather than standard office E/M. This will help me choose the correct code family and avoid burning a submission on the wrong billing model.

Args · stage documentation · 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]

#5 kb_coding_guidelines I need the formal E/M leveling rules before assigning the urgent care visit code, since documentation is sparse and... ＋

Agent reasoning

I need the formal E/M leveling rules before assigning the urgent care visit code, since documentation is sparse and we have only one likely billable service. I expect to confirm whether this new-patient ankle injury visit supports straightforward or low MDM and avoid burning a submission with the wrong E/M level.

Args · stage documentation · 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 capture_charges I need to capture the billable activity from the encounter before coding service lines so I can confirm whether... ＋

Agent reasoning

I need to capture the billable activity from the encounter before coding service lines so I can confirm whether anything besides the urgent care E/M is supported. This should surface all chargeable components from the chart and help avoid missing billable services.

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]

#7 kb_lookup_icd10 I need to verify the SNOMED-documented ankle condition to the exact ICD-10-CM code before setting Box 21. The note... ＋

Agent reasoning

I need to verify the SNOMED-documented ankle condition to the exact ICD-10-CM code before setting Box 21. The note supports a right ankle sprain after twisting injury, and I want to confirm the specific code description for an unspecified ligament sprain, initial encounter.

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."}

#8 review_documentation I’ve confirmed eligibility already, but before setting diagnoses and E/M I need a structured coder review to... ＋

Agent reasoning

I’ve confirmed eligibility already, but before setting diagnoses and E/M I need a structured coder review to identify any documentation ambiguity, billable elements, and whether a provider query is needed. This should help ensure we don’t miss charges or over/under-code the urgent care visit before using a submission attempt.

Args · stage charge_capture · day 0

{}

Result

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

#9 kb_lookup_icd10 I need to confirm the exact ICD-10-CM description for the ankle injury code already considered, since the note... ＋

Agent reasoning

I need to confirm the exact ICD-10-CM description for the ankle injury code already considered, since the note documents a right ankle twist with persistent pain and swelling and I must verify laterality/encounter specificity before setting diagnoses. This lookup will confirm whether S93.401A matches an unspecified ligament sprain of the right ankle, initial encounter.

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."}

#10 portal_login Eligibility is already confirmed, but the checklist still requires payer-portal access and I need portal access... ＋

Agent reasoning

Eligibility is already confirmed, but the checklist still requires payer-portal access and I need portal access later for submission status and ERA retrieval. I’ll log into the payer portal now so the case is fully staged before coding/submission.

Args · stage charge_capture · day 0

{}

Result

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

#11 set_diagnoses I already have enough chart detail to code the diagnosis, and the next needed concrete step is to populate Box 21... ＋

Agent reasoning

I already have enough chart detail to code the diagnosis, and the next needed concrete step is to populate Box 21 before building service lines. The documented condition is a right ankle sprain after twisting injury with this being the initial encounter, so I will set the ICD-10-CM diagnosis accordingly.

Args · stage coding · day 0

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

Result

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

#12 kb_coding_guidelines I need the urgent care/professional service-line coding rules before setting Box 24 because this chart only shows... ＋

Agent reasoning

I need the urgent care/professional service-line coding rules before setting Box 24 because this chart only shows clinical activity and no charge codes. I’m checking whether this payer/workflow expects a standard office E/M for POS 20 or an urgent-care global case-rate, so I can avoid a bad first submission.

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]

#13 portal_verify_otp The portal login was initiated but not completed, and logging in is required to satisfy the payer workflow checklist... ＋

Agent reasoning

The portal login was initiated but not completed, and logging in is required to satisfy the payer workflow checklist and later access ERA/EOB information. I will verify the OTP now so the portal session is active before final claim submission and remittance work.

Args · stage coding · day 0

{"code": "000000"}

Result

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

#14 kb_coding_guidelines I have the diagnosis set, but the claim cannot be submitted until I correctly derive and level the professional... ＋

Agent reasoning

I have the diagnosis set, but the claim cannot be submitted until I correctly derive and level the professional service line from the documentation. I’m checking the E/M rules now so I can choose the right new-patient urgent care office/outpatient code and avoid burning a submission on an under- or over-coded visit.

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 This urgent care visit documents a new-patient evaluation for an acute right ankle sprain with no separately... ＋

Agent reasoning

This urgent care visit documents a new-patient evaluation for an acute right ankle sprain with no separately billable procedures, imaging, drugs, or supplies. I need to set the professional service line now, using the new-patient E/M code that fits the documented low MDM and 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 validate the current coding before risking a submission. Running the scrub now will tell me exactly what... ＋

Agent reasoning

I need to validate the current coding before risking a submission. Running the scrub now will tell me exactly what claim elements are still missing or noncompliant so I can fix them deliberately.

Args · stage coding · day 0

{}

Result

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

#17 kb_lookup_payer_policy Before using one of the 3 submissions, I need to verify whether this payer expects urgent care encounters to bill a... ＋

Agent reasoning

Before using one of the 3 submissions, I need to verify whether this payer expects urgent care encounters to bill a UC global/case-rate code instead of a standard office E/M. That could materially change the service line and prevent an avoidable denial.

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"}}

#18 review_documentation Before spending a submission, I want to verify whether the current E/M level and diagnosis fully match the... ＋

Agent reasoning

Before spending a submission, I want to verify whether the current E/M level and diagnosis fully match the documentation, especially since the note is sparse and urgent care payer rules can differ. A documentation review may surface ambiguity or missed billable elements that need correction before claim submission.

Args · stage coding · day 0

{}

Result

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

#19 kb_lookup_em_guidelines The claim is coded and scrubbed clean, but before using a submission attempt I need to confirm the E/M level is... ＋

Agent reasoning

The claim is coded and scrubbed clean, but before using a submission attempt I need to confirm the E/M level is defensible against the official rules for 99203, since urgent care new-patient leveling is the main denial risk here. I expect to verify whether low MDM/15 minutes supports 99203 or whether the level should be changed before submission.

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."}

#20 kb_lookup_payer_policy The claim is coded and scrubbed clean, but Box 23/17b/header elements have not been reviewed directly from... ＋

Agent reasoning

The claim is coded and scrubbed clean, but Box 23/17b/header elements have not been reviewed directly from payer-specific requirements. I want to confirm whether Oxford Freedom requires any additional header data for a straightforward urgent care E/M with no ordered ancillary services or prior auth before using one of our limited submission attempts.

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"}}

#21 submit_claim The claim has already been coded, scrubbed clean, and coverage/COB are resolved; no auth or referring fields are... ＋

Agent reasoning

The claim has already been coded, scrubbed clean, and coverage/COB are resolved; no auth or referring fields are needed for this ankle-pain E/M-only urgent care visit. The next concrete step is to submit the 837P and see whether it clears intake and adjudicates without denial.

Args · stage remittance · day 23

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-14bc468392", "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]

#22 post_remittance The claim is already paid and the checklist shows the only remaining required step is to post the remittance so the... ＋

Agent reasoning

The claim is already paid and the checklist shows the only remaining required step is to post the remittance so the account is reconciled. I will post the 835 payment and patient responsibility now to complete the revenue-cycle workflow.

Args · stage closed_paid · day 23

{}

Result

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