ManikandanandClaude Opus 5.5
ba15a574ab
Snapshot of the working project as of 2026-10-23 (local 2d4d4fc), one commit with no earlier history: the tracked files were de-identified first (synthetic claim ids and patient data only; see Context.md section 7). Credentials, run logs, screenshots, claim reports and client workbooks are gitignored and not included. Co-Authored-By: Claude Opus 5.5 <noreply@anthropic.com>
425 lines
16 KiB
Python
425 lines
16 KiB
Python
r"""
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conditions/telehealth.py — the thin detect/apply/describe wrapper around
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Condition 1's existing logic.
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python tests\test_conditions_telehealth.py
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The actual DOM mechanics (`note_mentions_telehealth`, `set_cpt_pos_modifier`)
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are already covered exhaustively in test_telehealth_fix.py and do not move —
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this file only proves the wrapper calls them correctly and shapes the result
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the Condition Framework's runner expects. Reuses ub_claim.html, same as
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test_telehealth_fix.py, for the one case that needs a real form.
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"""
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import sys
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import pathlib
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import inspect
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ROOT = pathlib.Path(__file__).resolve().parent.parent
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sys.path.insert(0, str(ROOT / "src"))
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FIXTURE = pathlib.Path(__file__).resolve().parent / "fixtures" / "ub_claim.html"
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from ecw_bot.conditions import telehealth # noqa: E402
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from ecw_bot.conditions.base import ConditionResult # noqa: E402
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from ecw_bot.selectors import claim_form as sel # noqa: E402
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CASES = []
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def case(fn):
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CASES.append(fn)
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return fn
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@case
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def detect_true_when_the_note_mentions_telehealth():
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data = {"progress_notes": {"text": "Session Setting (PoS): TeleHealth"}}
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assert telehealth.detect("C1", data) is True
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@case
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def detect_true_for_telephone_and_standalone_th_too():
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assert telehealth.detect(
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"C1", {"progress_notes": {"text": "Mode of Treatment: Telephone"}}
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) is True
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assert telehealth.detect(
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"C1", {"progress_notes": {"text": "Visit type: TH"}}
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) is True
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@case
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def detect_false_with_no_progress_notes_key_at_all():
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"""A claim dict from extract() before Prog. Notes was opened — must not
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raise on the missing key, just report nothing to detect."""
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assert telehealth.detect("C1", {}) is False
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@case
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def detect_false_for_an_ordinary_note():
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data = {"progress_notes": {"text": "Regular in-office visit, no video."}}
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assert telehealth.detect("C1", data) is False
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# --- modifier selection (condition #21 of the Charge Condition Document) --
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#
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# `_choose_modifier` returns `(modifier, decline_reason)` since review item
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# D5 (2026-10-05), so apply() can tell "write this", "not covered"
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# (Medicare) and "declined" apart.
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@case
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def audio_only_is_modifier_93_for_commercial_payers():
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assert telehealth._choose_modifier("audio", "Aetna") == ("93", "")
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@case
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def video_is_modifier_95_for_commercial_payers():
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assert telehealth._choose_modifier("video", "Aetna") == ("95", "")
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@case
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def medicaid_is_always_gt_even_for_an_audio_only_visit():
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"""
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The client's own expected results (claims 9123000, 9124000, 9122000 —
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Medicaid-group telephone visits) keep or add GT, never 93: the
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document's "93 for Audio only" applies to Commercial, not Medicaid.
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"""
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assert telehealth._choose_modifier("audio", "BH COLORADO ACCESS") \
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== ("GT", "")
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assert telehealth._choose_modifier("audio", "Medicaid") == ("GT", "")
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@case
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def every_rae_payer_gets_gt_like_medicaid_audio_or_video():
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"""
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The nine RAE payers are grouped "RAE payer", not "Medicaid", in
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payer_groups.json — but they are Medicaid plans, and their telehealth
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rule is the Medicaid one: POS 2 + GT (confirmed 2026-09-24).
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"""
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for payer in ("BH COLORADO ACCESS", "BH ROCKY MOUNTAIN HEALTH",
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"BH ROCKY MTN HEALTH 2022", "BH ROCK MTN UB",
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"Carelon Behavioral Health, Inc",
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"CCH CO COMMUNITY HEALTH ALLIANCE", "HEALTH COLORADO INC",
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"Northeast Colorado Health Department",
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"Northeast Health Partners"):
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for mode in ("audio", "video"):
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assert telehealth._choose_modifier(mode, payer) == ("GT", ""), \
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(payer, mode)
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@case
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def medicare_is_not_covered_in_every_mode():
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"""
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The actual bug this test guards: before this was fixed, _choose_modifier
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checked mode == "audio" BEFORE the payer group, so an audio-only
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Medicare claim got 93 from THIS condition too — while
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medicare_telehealth.py also fired on the same row, double-writing it.
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Payer group must be checked first, in every mode — and "not covered"
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carries no decline reason: medicare_telehealth handles the claim, so
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it is not a review.
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"""
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for mode in ("audio", "video"):
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assert telehealth._choose_modifier(mode, "Humana Medicare") \
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== telehealth.NOT_COVERED == (None, "")
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@case
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def a_medicare_advantage_plan_gets_the_commercial_modifier():
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"""Ruling 2026-10-21: the dashboard's Commercial Ins — 93 / 95 (#21),
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not G2025 (#22)."""
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for plan in ("AARP Medicare Advantage", "Aetna Medicare ADV"):
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assert telehealth._choose_modifier("audio", plan) == ("93", "")
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assert telehealth._choose_modifier("video", plan) == ("95", "")
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@case
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def payers_with_no_rule_are_declined_with_a_reason_in_every_mode():
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"""
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Review item D5: the OLD expectation here was `_choose_modifier("audio",
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"") == "93"` — an unmapped or blank payer on an audio visit got 93
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written, because the audio branch ran before the payer lookup. An
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unclassified Medicare plan then got rule #21 where #22 applies, and an
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unmapped Medicaid MCO got 93 instead of GT. Now every payer with no
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telehealth modifier rule is declined, audio or video, with the payer
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and its group named.
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"""
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for payer, group in (("Some Unmapped Payer", "not in payer_groups.json"),
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("OUTREACH PROGRAM", "Program"),
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("DentaQuest", "Dentaquest")):
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for mode in ("audio", "video"):
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modifier, reason = telehealth._choose_modifier(mode, payer)
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assert modifier is None, (payer, mode, modifier)
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assert reason == (
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f"telehealth visit, but payer {payer!r} ({group}) has no "
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f"telehealth modifier rule — set POS/modifier by hand"), reason
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# A blank payer is a read that found no name, not an unmapped payer:
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# its reason says so instead of pointing at payer_groups.json (final
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# review, 2026-10-05; this case used to expect "payer '' (not in
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# payer_groups.json)").
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for mode in ("audio", "video"):
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for blank in ("", " "):
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modifier, reason = telehealth._choose_modifier(mode, blank)
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assert modifier is None, (blank, mode, modifier)
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assert reason == ("telehealth visit, but no primary payer name "
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"was read — set POS/modifier by hand"), reason
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@case
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def an_unloadable_mapping_is_declined_not_guessed():
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original = telehealth.payer_groups.load_mapping
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def broken():
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raise ValueError("bad JSON")
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telehealth.payer_groups.load_mapping = broken
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try:
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assert telehealth._choose_modifier("video", "Aetna") \
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== (None, "payer_groups.json could not be loaded")
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finally:
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telehealth.payer_groups.load_mapping = original
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# --- apply(), against the real fixture ------------------------------------
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_MEDICAID_DATA = {
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"progress_notes": {"text": "Session Setting (PoS): TeleHealth"},
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"insurance": [{"Name": "BH COLORADO ACCESS"}],
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}
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@case
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def apply_sets_pos_2_and_the_medicaid_modifier_on_the_first_row_only(page):
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page.goto(FIXTURE.as_uri())
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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assert isinstance(result, ConditionResult)
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assert result.condition_name == "telehealth"
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assert result.changed is True
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assert len(result.changes) == 1, result.changes
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assert result.changes[0]["code"] == "H0023", result.changes
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assert result.changes[0]["after"]["pos"] == "2", result.changes
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assert result.changes[0]["after"]["mod1"] == "GT", result.changes
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# Row 1 (90791) must be untouched — this condition is first-row-only.
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row1_mod1 = page.locator(sel.SEL_CPT_ROWS).nth(1).locator(
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sel.SEL_CPT_MOD1).first
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assert row1_mod1.input_value() != "GT", \
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"telehealth condition must not touch the second CPT row"
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@case
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def apply_keeps_gt_for_an_audio_only_visit_on_a_medicaid_payer(page):
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page.goto(FIXTURE.as_uri())
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data = {
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"progress_notes": {"text": "Mode of Treatment: Telephone"},
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"insurance": [{"Name": "BH COLORADO ACCESS"}],
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}
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result = telehealth.apply(page, "9120000", data)
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assert result.changed is True
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assert len(result.changes) == 1, result.changes
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assert result.changes[0]["after"]["mod1"] == "GT", result.changes
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@case
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def apply_uses_93_for_an_audio_only_visit_on_a_commercial_payer(page):
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page.goto(FIXTURE.as_uri())
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data = {
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"progress_notes": {"text": "Mode of Treatment: Telephone"},
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"insurance": [{"Name": "Aetna"}],
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}
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result = telehealth.apply(page, "9120000", data)
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assert result.changed is True
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assert result.changes[0]["after"]["mod1"] == "93", result.changes
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@case
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def apply_declines_every_payer_with_no_telehealth_rule(page):
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"""
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Review item D5: unmapped, blank, Program and Dentaquest payers are
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declined (a Review row with the reason), and nothing is written — the
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old behaviour was a quiet none() on video and 93 written on audio.
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"""
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for payer in ("Some Unmapped Payer", "", "OUTREACH PROGRAM",
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"DentaQuest"):
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for note in ("Session Setting (PoS): TeleHealth",
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"Mode of Treatment: Telephone"):
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page.goto(FIXTURE.as_uri())
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data = {"progress_notes": {"text": note},
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"insurance": [{"Name": payer}]}
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result = telehealth.apply(page, "9120000", data)
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assert result.changed is False and result.changes == [], result
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if payer:
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assert f"payer {payer!r}" in result.review, result.review
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assert "has no telehealth modifier rule" in result.review
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else:
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assert "no primary payer name was read" in result.review, \
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result.review
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row0 = page.locator(sel.SEL_CPT_ROWS).nth(0)
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assert row0.locator(sel.SEL_CPT_POS).first.input_value() == "11", \
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"a declined payer must leave the claim as read"
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@case
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def apply_uses_95_for_a_video_visit_on_a_commercial_payer(page):
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page.goto(FIXTURE.as_uri())
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data = {
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"progress_notes": {"text": "TELEHEALTH: real-time audio and video"},
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"insurance": [{"Name": "Aetna"}],
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}
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result = telehealth.apply(page, "9120000", data)
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assert result.changed is True and result.review == "", result
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assert result.changes[0]["after"]["mod1"] == "95", result.changes
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@case
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def apply_returns_none_not_review_for_a_medicare_payer(page):
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"""medicare_telehealth fires on the same claim and handles it — a
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review here would put a correctly handled claim in front of a human."""
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page.goto(FIXTURE.as_uri())
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data = {"progress_notes": {"text": "Mode of Treatment: Telephone"},
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"insurance": [{"Name": "Humana Medicare"}]}
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result = telehealth.apply(page, "9120000", data)
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assert result == ConditionResult.none("telehealth"), result
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@case
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def apply_returns_none_for_an_already_correct_claim(page):
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"""
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Review item D3: a claim whose primary row already holds POS 2 (eCW
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writes "02") and the right modifier is Pass, not "Corrections pending"
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— none(), no review.
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"""
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page.goto(FIXTURE.as_uri())
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row0 = page.locator(sel.SEL_CPT_ROWS).nth(0)
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row0.locator(sel.SEL_CPT_POS).first.fill("02") # M1 is already GT
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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assert result == ConditionResult.none("telehealth"), result
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assert row0.locator(sel.SEL_CPT_POS).first.input_value() == "02"
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@case
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def apply_sends_a_write_that_did_not_take_to_review(page):
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"""A POS that reads back wrong after the fill (eCW reformatting it,
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a field that ignores input) is kept in the result but marked review."""
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page.goto(FIXTURE.as_uri())
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page.evaluate("""() => {
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const el = document.getElementById('uBClaimPOS0');
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el.addEventListener('input', () => { el.value = '11'; });
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}""")
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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assert result.changed is True, result
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assert result.changes[0]["ok"] is False, result.changes
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assert result.review == ("POS/modifier did not take on row 1 — set it "
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"by hand"), result.review
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assert "did NOT take" in telehealth.describe(result)
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@case
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def describe_and_summary_comment_say_what_actually_changed(page):
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page.goto(FIXTURE.as_uri())
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data = {"progress_notes": {"text": "TELEHEALTH: audio only visit"},
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"insurance": [{"Name": "Aetna"}]}
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result = telehealth.apply(page, "9120000", data)
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text = telehealth.describe(result)
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assert 'mode audio (matched "audio only")' in text, text
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assert "93" in text and "H0023" in text, text
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assert telehealth.summary_comment(result) == \
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"Telehealth (POS 02, modifier 93 on H0023)"
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page.goto(FIXTURE.as_uri())
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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assert "mode video (default — no audio-only evidence)" in \
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telehealth.describe(result)
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# The fixture's row already has M1 GT, so only POS was fixed — and only
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# POS is named (final review, 2026-10-05; this used to expect
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# "POS 02, modifier GT on H0023", reading the correct M1 as a fix).
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assert telehealth.summary_comment(result) == \
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"Telehealth (POS 02 on H0023)"
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@case
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def describe_mentions_the_changed_row(page):
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page.goto(FIXTURE.as_uri())
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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text = telehealth.describe(result)
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assert "H0023" in text, text
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assert "POS" in text and "GT" in text, text
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# _MEDICAID_DATA's note text is "Session Setting (PoS): TeleHealth" —
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# the "telehealth" signal, not "telephone" or a TH tag — so the
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# operator can see WHY this fired, not just that it did.
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assert "telehealth" in text, text
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@case
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def a_live_grid_that_reads_empty_after_a_full_first_read_is_declined(page):
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"""
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Final review, 2026-10-05: the claim's first read had CPT rows, but the
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live grid apply() re-read had none (not re-rendered after the tab
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re-click). The fix was never applied — declined (Review), not none()
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(Pass). With no CPT rows in the first read either it stays none().
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"""
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from ecw_bot.conditions.base import CPT_GRID_NOT_READ
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page.goto(FIXTURE.as_uri())
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page.evaluate("""() => document.querySelectorAll('tr[id^="CPTROW_"]')
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.forEach(r => r.remove())""")
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result = telehealth.apply(page, "9120000",
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dict(_MEDICAID_DATA, cpt=[{"code": "H0023"}]))
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assert result == ConditionResult.declined("telehealth",
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CPT_GRID_NOT_READ), result
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page.goto(FIXTURE.as_uri())
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page.evaluate("""() => document.querySelectorAll('tr[id^="CPTROW_"]')
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.forEach(r => r.remove())""")
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result = telehealth.apply(page, "9120000", _MEDICAID_DATA)
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assert result == ConditionResult.none("telehealth"), result
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@case
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def summary_comment_names_only_the_field_that_was_fixed():
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def row(pos, mod):
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return {"row": 0, "code": "99213", "changed": True, "ok": True,
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"before": {"pos": pos, "mod1": mod},
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"after": {"pos": "2", "mod1": "GT"}, "modifier": "GT"}
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sc = telehealth.summary_comment
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mk = lambda c: ConditionResult("telehealth", True, [c])
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assert sc(mk(row("11", "GT"))) == "Telehealth (POS 02 on 99213)"
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assert sc(mk(row("02", ""))) == "Telehealth (modifier GT on 99213)"
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assert sc(mk(row("11", "95"))) == \
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"Telehealth (POS 02, modifier GT on 99213)"
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def main() -> int:
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if not FIXTURE.exists():
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print(f" FAIL fixture missing: {FIXTURE}")
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return 1
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try:
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from playwright.sync_api import sync_playwright
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except ImportError:
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print(" SKIP playwright is not installed")
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return 0
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failures = 0
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with sync_playwright() as pw:
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browser = pw.chromium.launch(headless=True)
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page = browser.new_page()
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for fn in CASES:
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name = fn.__name__.replace("_", " ")
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try:
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if len(inspect.signature(fn).parameters) == 0:
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fn()
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else:
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fn(page)
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print(f" ok {name}")
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except AssertionError as exc:
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print(f" FAIL {name}: {exc}")
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failures += 1
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except Exception as exc:
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print(f" ERROR {name}: {type(exc).__name__}: {exc}")
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failures += 1
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browser.close()
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print(f"\n{len(CASES) - failures}/{len(CASES)} passed")
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return 1 if failures else 0
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if __name__ == "__main__":
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sys.exit(main())
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