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Trajectory · Claim #95187 · 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 · 20 tool calls

#0 check_eligibility First I need to confirm active coverage because eligibility must be verified before billing and it may also reveal... ＋

Agent reasoning

First I need to confirm active coverage because eligibility must be verified before billing and it may also reveal COB/other payer information. The chart notes member was active, but I need the formal 270/271 result in the workflow state before proceeding.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "HEALTHFIRST OF NEW YORK GR", "member_id": "MD7B81D3E7", "group": "GRP-4677", "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 and CPT/E/M, especially because the note is... ＋

Agent reasoning

I need a structured coder review of the chart before assigning ICD-10 and CPT/E/M, especially because the note is sparse and may have ambiguities affecting diagnosis specificity and level selection. This should confirm what is actually documented, identify any missing elements, and tell me whether a provider query is needed.

Args · stage documentation · day 0

{}

Result

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

#2 capture_charges I need the chart-derived activity inventory before coding so I can be sure I capture every billable charge and... ＋

Agent reasoning

I need the chart-derived activity inventory before coding so I can be sure I capture every billable charge and confirm whether this visit should be billed as only an office/urgent-care E/M. This should surface any missed professional charges from the encounter documentation.

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]

#3 read_chart I need to verify the exact diagnosis documented by the SNOMED/problem and note before setting Box 21, because the... ＋

Agent reasoning

I need to verify the exact diagnosis documented by the SNOMED/problem and note before setting Box 21, because the chart says lifelong eczema with dry atrophic skin on bilateral hands and face but the coded diagnosis must match the condition precisely. I’m reading the chart section again to confirm there are no additional assessed problems, treatments, or ambiguity that would affect ICD-10 specificity and E/M leveling.

Args · stage charge_capture · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:46:00  |  End Time: 15:01:00  |  Length of Stay: 15 min  |  Reason: Dry skin on hand and face  |  Visit type: NCH - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nGeneral: pt has eczema all his life and needs cream for it\n[EXTREMITIES:] no clubbing, cyanosis, or edema\n[SKIN:] dry, atrophic skin noted to bilateral hands over mcp joints\n[NEUROLOGIC:] nonfocal, motor strength normal  …[truncated]

#4 kb_coding_guidelines I need the official coding rules before assigning ICD-10 and leveling the E/M, because this urgent care new-patient... ＋

Agent reasoning

I need the official coding rules before assigning ICD-10 and leveling the E/M, because this urgent care new-patient visit has sparse documentation and I must avoid a wasted submission. I expect to confirm whether to use standard office/outpatient E/M for POS 20 and how to level from MDM vs time with the documented elements.

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]

#5 kb_lookup_payer_policy I have enough chart detail to start coding, but before setting diagnoses and service lines I need payer-specific... ＋

Agent reasoning

I have enough chart detail to start coding, but before setting diagnoses and service lines I need payer-specific billing rules to avoid burning a submission on a companion-guide requirement such as urgent care coding, taxonomy, or referring/auth conventions for this payer. I expect to confirm whether standard office E/M is appropriate for POS 20 under Healthfirst Medicaid and whether any payer edits apply.

Args · stage charge_capture · day 0

{}

Result

{"payer": "HEALTHFIRST OF NEW YORK GR", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 266, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 36, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "44736"}}

#6 kb_lookup_icd10 I need to verify the diagnosis translation from the documented SNOMED/problem before setting Box 21. The note... ＋

Agent reasoning

I need to verify the diagnosis translation from the documented SNOMED/problem before setting Box 21. The note describes chronic eczema with dry atrophic skin on bilateral hands, so I’m confirming the ICD-10-CM code I intend to use is valid and correctly described.

Args · stage charge_capture · day 0

{"code": "L30.9"}

Result

{"code": "L30.9", "found": false, "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#7 read_chart I need to verify the exact SNOMED diagnosis from the chart before assigning ICD-10, since the earlier L30.9 lookup... ＋

Agent reasoning

I need to verify the exact SNOMED diagnosis from the chart before assigning ICD-10, since the earlier L30.9 lookup warned that specificity must be supported. Re-reading the diagnoses/problem content should confirm whether this is documented simply as eczema/dermatitis without greater specificity.

Args · stage charge_capture · day 0

{"section": "diagnoses"}

Result

{"section": "diagnoses", "body": "(no such section)"}

#8 kb_coding_guidelines I need the full coding/workflow rules specific to this encounter before committing diagnosis and service lines,... ＋

Agent reasoning

I need the full coding/workflow rules specific to this encounter before committing diagnosis and service lines, especially urgent care/global billing and E/M selection requirements for this payer context. I expect this to clarify whether to bill a standard new-patient E/M versus any urgent-care-specific case-rate and help avoid wasting a submission.

Args · stage charge_capture · 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]

#9 kb_lookup_payer_policy I need the official payer companion-guide details before coding/submitting so I can confirm any Healthfirst-specific... ＋

Agent reasoning

I need the official payer companion-guide details before coding/submitting so I can confirm any Healthfirst-specific requirements around urgent care billing, taxonomy, and header/referring/auth rules that could cause an avoidable denial. This should help me validate whether a standard office E/M in POS 20 is acceptable for this payer and what claim elements are mandatory.

Args · stage charge_capture · day 0

{}

Result

{"payer": "HEALTHFIRST OF NEW YORK GR", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 266, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 36, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "44736"}}

#10 portal_login I need payer-portal access before submission so I can complete the required portal step and be ready to review any... ＋

Agent reasoning

I need payer-portal access before submission so I can complete the required portal step and be ready to review any payer-side details/ERA after adjudication. The case is already eligibility-verified, so logging in is the next concrete workflow step.

Args · stage charge_capture · day 0

{}

Result

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

#11 portal_verify_otp I need portal access completed before submission work is finalized, and the last system action indicates OTP is... ＋

Agent reasoning

I need portal access completed before submission work is finalized, and the last system action indicates OTP is ready. Verifying the OTP should let me log in so I can satisfy the payer-portal step and access any payer-side claim/ERA functions later if needed.

Args · stage charge_capture · day 0

{"code": "000000"}

Result

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

#12 read_chart I need the full chart details that drive ICD-10 specificity and E/M level before setting diagnoses and service... ＋

Agent reasoning

I need the full chart details that drive ICD-10 specificity and E/M level before setting diagnoses and service lines. I’m reopening the progress note to confirm whether there is any documented treatment, prescription management, or facial involvement that would justify a more specific dermatitis code or higher MDM.

Args · stage charge_capture · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:46:00  |  End Time: 15:01:00  |  Length of Stay: 15 min  |  Reason: Dry skin on hand and face  |  Visit type: NCH - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nGeneral: pt has eczema all his life and needs cream for it\n[EXTREMITIES:] no clubbing, cyanosis, or edema\n[SKIN:] dry, atrophic skin noted to bilateral hands over mcp joints\n[NEUROLOGIC:] nonfocal, motor strength normal  …[truncated]

#13 set_diagnoses The documentation supports a single diagnosis of chronic eczema/atopic dermatitis affecting the hands, and the... ＋

Agent reasoning

The documentation supports a single diagnosis of chronic eczema/atopic dermatitis affecting the hands, and the prompt indicates I have enough to commit the ICD-10-CM now. I’ll set the diagnosis so I can move on to deriving the professional service line and scrubbing the claim.

Args · stage coding · day 0

{"codes": ["L30.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "L30.9"}]}

#14 kb_coding_guidelines I need to confirm the exact E/M leveling rules for a new patient urgent-care professional claim before setting Box... ＋

Agent reasoning

I need to confirm the exact E/M leveling rules for a new patient urgent-care professional claim before setting Box 24, since this chart has sparse MDM/time documentation and we only have one submission budgeted initially. I expect to use the official guideline details to choose the correct new-patient E/M level rather than guessing low or overcoding.

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 a professional E/M service for a new urgent-care visit: one chronic skin condition addressed... ＋

Agent reasoning

The chart supports only a professional E/M service for a new urgent-care visit: one chronic skin condition addressed with no orders, procedures, or separately billable supplies/drugs. Based on the documented minimal problem burden/data/risk and 15 minutes total visit span, I will set a single new-patient office/other outpatient E/M line at POS 20 linked to the eczema diagnosis.

Args · stage coding · day 0

{"lines": [{"cpt": "99202", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99202", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#16 run_scrub The current claim already has a diagnosis and E/M line, but I need to confirm there are no hidden scrub issues... ＋

Agent reasoning

The current claim already has a diagnosis and E/M line, but I need to confirm there are no hidden scrub issues before spending a submission attempt. Running the pre-submission scrub now will show any missing required elements or coding edits that must be fixed first.

Args · stage coding · day 0

{}

Result

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

#17 kb_lookup_em_guidelines The claim is already coded and scrub-clean, but before using a limited submission I want to validate that the... ＋

Agent reasoning

The claim is already coded and scrub-clean, but before using a limited submission I want to validate that the selected E/M exactly matches 2024 office/outpatient new-patient guidelines for this documented 15-minute urgent care visit with one stable chronic skin condition and no data/risk. This will confirm whether 99202 is supportable or whether the level should be changed before submission.

Args · stage coding · day 0

{"level": "99202"}

Result

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

#18 submit_claim I’ve verified the key coding elements already and the scrub is clean, so the next safest step is to submit the... ＋

Agent reasoning

I’ve verified the key coding elements already and the scrub is clean, so the next safest step is to submit the initial 837P and see whether payer intake and adjudication accept this coding. This will advance the case to either a payable remit or a specific denial reason we can correct without guessing.

Args · stage remittance · day 38

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-fb4908a1ef", "status": "paid", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100, "claim_control_number": "CCN95187-1", "lines": [{"cpt": "99202", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100}], "carcs": [], "rarcs": [], "posted": false, "transaction": "835"}, "era_text": "835 ERA / EOB   CCN=CCN …[truncated]

#19 post_remittance The claim is already paid and the checklist shows the only remaining required step is remittance posting. I will... ＋

Agent reasoning

The claim is already paid and the checklist shows the only remaining required step is remittance posting. I will post the paid ERA to reconcile the $125 payment, $0 patient responsibility, and $1 contractual adjustment so the case can be closed cleanly.

Args · stage closed_paid · day 38

{}

Result

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