Insurance CPT Limits

1. What does this feature do? (High-Level Overview)

Insurance CPT Limits let administrators define the maximum number of daily units allowed per CPT code for a specific insurance and location combination. When a session note is submitted, the system enforces that the patient’s total units for that day do not exceed the configured cap, preventing over-billing. This feature is currently available in production.

2. Who is this for? (Roles & Permissions)

• Owner / Manager (with manage_insurances permission): Can create, edit, and delete CPT limits.
• RBT / BCBA (providers): Are indirectly affected — the system blocks note submission when a limit would be exceeded.

3. Business Rules & Enforcements

• Rule 1: A limit is defined per unique combination of insurance + location + CPT code. Duplicate combinations are rejected by the system.
• Rule 2: The four supported CPT codes are: 97151, 97153, 97155, and 97156.
• Rule 3: A max_per_day value of 0 means unlimited — no daily unit cap is enforced for that combination.
• Rule 4: A value greater than 0 enforces a strict daily maximum. When a note is created or updated, the system totals all non-voided RBT and BCBA notes for the same patient, session date, and CPT code. If the new total would exceed the limit, the note is rejected with an error indicating units available.
• Rule 5: If no limit is configured for an insurance + location + CPT code combination, the system blocks note creation entirely for that combination and requires a limit to be set up first.
• Rule 6: When updating an existing note, the system excludes that note from the existing unit count to avoid self-blocking.
• Rule 7: CPT limits can be copied from one location to another, or from one insurance to another, without manually re-entering each limit.

4. UI Placement

• Billing → Insurances → [Select Insurance] → Edit → CPT Code Limit by Location tab (tab 5 within the insurance edit view).

5. How-To Guide (Step-by-Step)

Scenario A: Adding a CPT limit for a location

1. Navigate to Billing → Insurances and click Edit on the target insurance.
2. Open the CPT Code Limit by Location tab.
3. Click Add CPT Limit.
4. In the modal, select the Location, choose the CPT Code, and enter the Max Units/Day (use 0 for unlimited).
5. Save. The limit takes effect immediately for any new or updated notes.

Scenario B: Editing or removing an existing limit

1. Navigate to the same CPT Code Limit by Location tab for the insurance.
2. Locate the row for the location and CPT code combination you want to change.
3. Click Edit to update the Max Units/Day value, or Delete to remove the limit entirely.
4. Save. Note: deleting a limit will block new note creation for that combination until a new limit is configured (see Rule 5).

6. What happens if…? (Edge Cases / FAQ)

• Q: What happens if no limit is configured for a CPT code at a given location?

  • A: The system blocks note creation for that insurance + location + CPT code combination and shows an error asking the administrator to configure a limit before notes can be submitted.

• Q: What does setting the limit to 0 mean?

  • A: A limit of 0 is treated as unlimited. The system skips the daily unit check entirely for that combination, allowing any number of units to be logged.

• Q: Does the daily limit apply across all patients or per patient?

  • A: Per patient. The system checks the total non-voided units for the specific patient on the session date, across both RBT and BCBA notes. Other patients are not affected.