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Trajectory · Claim #95187 · trial 3

GPT-5.4 openai

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

Reward

0.80

Coding

100%

Tool calls

Final stage

closed_paid

Tool-by-tool trajectory · 31 tool calls

#0 check_eligibility I need to confirm active coverage and benefits first because eligibility verification is required before any coding... ＋

Agent reasoning

I need to confirm active coverage and benefits first because eligibility verification is required before any coding or submission work. This should establish whether the member is active on the date of service and whether any COB issues need to be addressed.

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 to review the documentation in a structured way before assigning ICD-10 and E/M, especially because the note... ＋

Agent reasoning

I need to review the documentation in a structured way before assigning ICD-10 and E/M, especially because the note is sparse and may require clarification about the exact diagnosis/severity and any treatment performed. This should surface coding-relevant details and flag any ambiguity needing a provider query before we submit.

Args · stage documentation · day 0

{}

Result

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

#2 capture_charges I need to identify the actual billable activity recorded in the encounter before assigning CPT/HCPCS. Capturing... ＋

Agent reasoning

I need to identify the actual billable activity recorded in the encounter before assigning CPT/HCPCS. Capturing charges now will confirm whether only a professional E/M is supported or if any additional billable services were performed and missed.

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 kb_lookup_icd10 I need to verify the diagnosis from the SNOMED-linked documentation before setting Box 21. The note supports chronic... ＋

Agent reasoning

I need to verify the diagnosis from the SNOMED-linked documentation before setting Box 21. The note supports chronic eczema/dermatitis of the hands, and I want to confirm the exact ICD-10-CM description for the code I plan to use.

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."}

#4 kb_coding_guidelines I need the official E/M coding rules before assigning a new-patient urgent care visit level from this sparse... ＋

Agent reasoning

I need the official E/M coding rules before assigning a new-patient urgent care visit level from this sparse documentation. I’m checking the E/M guideline criteria so I can choose the correct office/outpatient new patient CPT and avoid wasting a submission on an under- or over-coded 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]

#5 kb_lookup_icd10 I need to verify the exact SNOMED-to-ICD translation before setting Box 21. The note documents chronic eczema with... ＋

Agent reasoning

I need to verify the exact SNOMED-to-ICD translation before setting Box 21. The note documents chronic eczema with dry atrophic skin on bilateral hands only, so I want to confirm the official description for the dermatitis code I plan to use.

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."}

#6 portal_login The checklist still requires payer-portal login, and the workflow guidance recommends logging in before submission... ＋

Agent reasoning

The checklist still requires payer-portal login, and the workflow guidance recommends logging in before submission so we can later retrieve acknowledgments/ERA without delay. I’ll initiate portal access now; this should move the case toward submission readiness and any portal-only payer policy details if needed.

Args · stage charge_capture · day 0

{}

Result

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

#7 portal_verify_otp I need payer-portal access completed before submission so I can satisfy the portal-login checklist item and be ready... ＋

Agent reasoning

I need payer-portal access completed before submission so I can satisfy the portal-login checklist item and be ready to retrieve ERA/EOB later. The OTP is already provided in the last result, so I will verify it now.

Args · stage charge_capture · day 0

{"code": "000000"}

Result

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

#8 review_documentation I need to verify exactly what diagnosis SNOMED 43116000 represents before finalizing ICD-10 selection, since the... ＋

Agent reasoning

I need to verify exactly what diagnosis SNOMED 43116000 represents before finalizing ICD-10 selection, since the note says eczema but the chart only exposes the SNOMED identifier. Re-reading the chart review output should clarify whether there is any ambiguity that would require a provider query or support a more specific dermatitis code than unspecified eczema.

Args · stage charge_capture · day 0

{}

Result

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

#9 read_chart I need to inspect the detailed chart sections again to code the diagnosis and level the professional service... ＋

Agent reasoning

I need to inspect the detailed chart sections again to code the diagnosis and level the professional service accurately from the actual documentation, especially since the note is sparse and the diagnosis is only in SNOMED. Reading the progress note will confirm the clinical problem, visit type, time, and whether any additional billable services or ordered items exist before I set Box 21 and Box 24.

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]

#10 kb_lookup_icd10 I need the official description for the documented SNOMED problem before setting Box 21. The chart says lifelong... ＋

Agent reasoning

I need the official description for the documented SNOMED problem before setting Box 21. The chart says lifelong eczema with dry atrophic skin on bilateral hands, so I’m verifying whether L30.9 is the correct ICD-10 description for this nonspecific eczema/dermatitis presentation.

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."}

#11 set_diagnoses The chart supports a single skin diagnosis: lifelong eczema/dry atrophic skin of bilateral hands without more... ＋

Agent reasoning

The chart supports a single skin diagnosis: lifelong eczema/dry atrophic skin of bilateral hands without more specific type documented. I need to commit the ICD-10-CM diagnosis now so the claim can progress to service-line coding and scrub.

Args · stage coding · day 0

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

Result

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

#12 kb_coding_guidelines I have the diagnosis set, but before assigning the E/M service line I need the official coding rules for... ＋

Agent reasoning

I have the diagnosis set, but before assigning the E/M service line I need the official coding rules for professional E/M leveling so I can choose the correct new-patient urgent-care office/outpatient level from the documented MDM/time. I expect to confirm whether this encounter supports 99202 versus a higher level and avoid a wasted 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]

#13 set_service_lines The chart supports only a single new-patient urgent care E/M with no separately billable procedures, drugs, labs, or... ＋

Agent reasoning

The chart supports only a single new-patient urgent care E/M with no separately billable procedures, drugs, labs, or imaging. Based on 1 chronic condition addressed with evaluation and treatment need but no data review and no documented Rx management/procedure, I will set a low-level new patient E/M line linked to the eczema diagnosis at POS 20 so the claim can move to scrub.

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": ""}]}

#14 kb_lookup_payer_policy Before risking a submission, I need the payer-specific companion-guide edits for this plan, especially whether... ＋

Agent reasoning

Before risking a submission, I need the payer-specific companion-guide edits for this plan, especially whether Healthfirst Medicaid expects urgent care to bill a UC global/case-rate code instead of a standard office E/M in POS 20. This will tell me if the current 99203 line is structurally wrong and what claim-header/provider requirements must be met before scrubbing.

Args · stage coding · 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"}}

#15 run_scrub Before burning a submission, I need the claim scrub to identify any remaining payer/edit issues such as taxonomy,... ＋

Agent reasoning

Before burning a submission, I need the claim scrub to identify any remaining payer/edit issues such as taxonomy, POS, or missing header elements. The coding appears simple, so the scrub result will tell me exactly what must be corrected before submission.

Args · stage coding · day 0

{}

Result

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

#16 kb_coding_guidelines Before spending a submission, I need to confirm whether urgent care visits for this payer should be billed as a... ＋

Agent reasoning

Before spending a submission, I need to confirm whether urgent care visits for this payer should be billed as a global/case-rate service instead of a standard office E/M, since the chart is POS 20 urgent care and the instructions specifically warn about urgent-care global billing. This will tell me if the current 99203 is appropriate or needs to be changed before submission.

Args · stage coding · 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]

#17 review_documentation The current chart is sparse and the existing coding may be too generic for diagnosis specificity and E/M support. I... ＋

Agent reasoning

The current chart is sparse and the existing coding may be too generic for diagnosis specificity and E/M support. I want a fresh coder review to confirm whether the documented condition supports a more specific dermatitis code and whether any documentation ambiguity or missed billable elements remain before risking the first submission.

Args · stage coding · day 0

{}

Result

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

#18 kb_lookup_em_guidelines The claim is already coded and scrub-clean, but before burning the first submission I need to validate whether the... ＋

Agent reasoning

The claim is already coded and scrub-clean, but before burning the first submission I need to validate whether the current new-patient E/M level is defensible from the official level criteria for this exact code. I expect to confirm 99203 aligns with the documented low MDM/new urgent care visit and avoid an avoidable denial or downcode issue.

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."}

#19 submit_claim The claim is already coded, scrubbed clean, and all prerequisite workflow items shown in status are completed, with... ＋

Agent reasoning

The claim is already coded, scrubbed clean, and all prerequisite workflow items shown in status are completed, with no COB, auth, query, drug, or referring-provider issues applicable to this simple office E/M. The next concrete step is to submit this first-pass claim and obtain the 999/277CA intake plus remittance outcome so we can confirm payment or work any denial without wasting submissions.

Args · stage denial · day 38

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-8e51ae1897", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-1", "lines": [{"cpt": "99203", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-150", "rarcs": ["M25"]}], "carcs": ["CO-150"], "rarcs": ["M25"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-135c1693bf", "stage": "adjudication",  …[truncated]

#20 kb_lookup_carc The denial specifically says the E/M level is unsupported and suggests reconciling charges against the chart, so... ＋

Agent reasoning

The denial specifically says the E/M level is unsupported and suggests reconciling charges against the chart, so before risking another submission I need the full coding/remedy guidance for CO-150/M25 to confirm whether the correction should be a lower E/M level or another coding change. This will help target the resubmission correctly and avoid burning a retry.

Args · stage denial · day 38

{"carc": "CO-150"}

Result

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

#21 portal_download_era The denial specifically says the E/M level is not supported and that there may be unbilled services, so before... ＋

Agent reasoning

The denial specifically says the E/M level is not supported and that there may be unbilled services, so before spending a resubmission I need the full remit details to confirm exactly how Healthfirst adjudicated the line and whether any additional denial remarks or line-level clues are present beyond the summary status.

Args · stage denial · day 38

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN95187-1\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    99203: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-8e51ae1897", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-1", "li …[truncated]

#22 read_chart The denial specifically says the E/M level is unsupported and hints the chart may support a different coding after... ＋

Agent reasoning

The denial specifically says the E/M level is unsupported and hints the chart may support a different coding after full reconciliation. I need to re-open the chart sections together to confirm whether there is any documented MDM, treatment, or additional billable activity that would support 99203 versus a lower new-patient E/M, before changing and risking a resubmission.

Args · stage denial · day 38

{"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]

#23 kb_coding_guidelines The denial is for unsupported E/M level, so before using one of the two remaining submissions I need the formal E/M... ＋

Agent reasoning

The denial is for unsupported E/M level, so before using one of the two remaining submissions I need the formal E/M rules to determine the correct new-patient urgent care level from the sparse documentation and 15-minute visit length. I expect this to confirm whether 99202 is the supported level instead of the denied 99203.

Args · stage denial · day 38

{"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]

#24 review_documentation The denial specifically says the E/M level is unsupported and hints there may be other unbilled documented services,... ＋

Agent reasoning

The denial specifically says the E/M level is unsupported and hints there may be other unbilled documented services, so before burning a resubmission I need a fresh coder review focused on missed billable activity and the correct code family/level for this urgent-care visit. I expect this to clarify whether the line should be downcoded, switched from office E/M to an urgent-care/global code, or supplemented with any missing charge.

Args · stage denial · day 38

{}

Result

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

#25 kb_coding_guidelines The denial specifically says the billed E/M level is unsupported and suggests reconciling any unbilled services, so... ＋

Agent reasoning

The denial specifically says the billed E/M level is unsupported and suggests reconciling any unbilled services, so before changing the coding I need the claim-building rules that apply to urgent care/global billing versus office E/M for this payer/workflow. I expect this to clarify whether POS 20 here should be billed as a UC global case-rate instead of 99203, which would change the resubmission strategy and avoid wasting a retry.

Args · stage denial · day 38

{"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]

#26 set_service_lines The denial is for unsupported E/M level, and the initial 99203 likely overstates this very limited new-patient... ＋

Agent reasoning

The denial is for unsupported E/M level, and the initial 99203 likely overstates this very limited new-patient eczema visit. I’m changing the professional line to a lower new-patient E/M that better fits one stable chronic problem with minimal/no data and low risk, so the resubmission differs from the denied coding.

Args · stage coding · day 38

{"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": ""}]}

#27 run_scrub The initial 99203 was denied for unsupported E/M level, and 99202 has now been set but not yet scrubbed or... ＋

Agent reasoning

The initial 99203 was denied for unsupported E/M level, and 99202 has now been set but not yet scrubbed or resubmitted. Before using a limited retry, I need to run the pre-submission scrub to confirm the corrected claim is clean and that no other header/line issues will cause avoidable denial.

Args · stage coding · day 38

{}

Result

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

#28 portal_download_era The claim denied for unsupported E/M level, and with only two submissions left I need the full remittance details to... ＋

Agent reasoning

The claim denied for unsupported E/M level, and with only two submissions left I need the full remittance details to confirm exactly what line/code adjudicated and whether there are any additional payer remarks beyond the summary denial text. I expect the ERA/EOB to clarify the denied billed CPT and guide the safest corrected resubmission.

Args · stage remittance · day 76

{}

Result

{"ok": false, "error": "Your corrected claim is scrubbed CLEAN and differs from what you already submitted - TRANSMIT IT NOW: submit_claim. You have 2 of 3 attempts left. Re-coding, lookups, and re-scrubbing are paused until you resubmit this claim.", "must_call_next": "submit_claim"}

#29 submit_claim The corrected claim has already been changed from the originally denied 99203 to 99202, the scrub is clean, and the... ＋

Agent reasoning

The corrected claim has already been changed from the originally denied 99203 to 99202, the scrub is clean, and the system explicitly instructs that re-coding and re-scrubbing are paused until resubmission. I am transmitting the corrected professional claim now to use the second submission attempt and obtain updated adjudication.

Args · stage closed_paid · day 76

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-e37220130a", "status": "paid", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100, "claim_control_number": "CCN95187-2", "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]

#30 post_remittance The corrected claim has already been accepted and the 835 shows paid, but the remit is not yet posted. The next... ＋

Agent reasoning

The corrected claim has already been accepted and the 835 shows paid, but the remit is not yet posted. The next required workflow step is to post the remittance so payment, contractual adjustment, and patient responsibility are reconciled and the checklist can be completed.

Args · stage None · day None

{}

Result

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