This is the Quality Contributions Roundup. It showcases interesting and well-written comments and posts from the period covered. If you want to get an idea of what this community is about or how we want you to participate, look no further (except the rules maybe--those might be important too).
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These are mostly chronologically ordered, but I have in some cases tried to cluster comments by topic so if there is something you are looking for (or trying to avoid), this might be helpful.
Quality Contributions to the Main Motte
Contributions for the week of July 28, 2025
@kky:
Contributions for the week of August 4, 2025
Gun Mods
Contributions for the week of August 11, 2025
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Notes -
I really don't feel like my comment was AAQC worthy, but ours is not to reason why I suppose.
I apologize because this is going to be by its nature rather rude and unavoidably direct, but you didn't engage the first time + your comment got a large number of upvotes and since it's reappeared as a AAQC... I need to point out again that your comment is factually inaccurate.
I don't think this is specifically your fault, insurance companies are notorious for inappropriately denying claims (and of course see United and Luigi in the news). It seems likely that inadequate or incorrect training is the norm. Additionally major aspects of the billing process have been revised on multiple occasions.
So:
Yes it is true that medical services are typically billed via CPT in most contexts.
Yes it is true that your bill can usually get adjusted if you complain (but that isn't necessarily because you are correct, it's because "Karening" works).
But, no. No that is not how CPT codes (specifically E/M) work at all.
First and probably most importantly, that's not how "time" works.
Time spent reviewing records and documentation on the patient, time spent interacting with the patient, time spent on orders afterword, time spent on documentation, and time spent on coordination of care (which can easily be very, very long) all count as time.
While it varies depending on the complexity of the patient and the specialty, it is not uncommon for a 5 to 15 minute encounter (time spent in the room with the patient) to generate a 45 to 60 minute or more encounter (time spent working on the patient).
Your surgeon may walk into the room, talk to you briefly, and leave - but they spent 20 minutes on the phone with radiology and another 20 minutes reviewing your records. ID and Psych are notorious for writing up notes that can be pages and pages and take up a related amount of time.
For a simple yearly family medicine appointment they manage to be pretty close but for specialists...no.
The other billing option is to do so by complexity, which involves extremely complicated rules and expert level knowledge to effectively audit.
It is therefore functionally impossible for a patient to evaluate the accuracy of an E/M code, even if they had the complete chart and the expert level knowledge of that specific specialty, the physician may have used time based billing and ended up on the phone with the pharmacy for 25 minutes, therefore justifying the code.
Again sorry to just "you are wrong" but in addition to the "help help someone is wrong on the internet" urge, your information also has a reasonably decent chance of generating some cringe moments where people using it are making a huge ass out of themselves by arguing and not realizing they are incorrect.
I want to again emphasize that while upcoding is a real thing it is a very serious battle between regulators, insurance, and health systems all trying to keep each other honest. Hospitals have a strong incentive to exactly follow the letter of the law because medicare can come in six months later, audit, and remove hundreds of thousands to millions or more of billing if things aren't exactly correct.
In addition the federal government loves to sniff out fraud and will send you to federal pound me in the ass prison.
Insurance companies engage in malfeasance because errors on their end don't kill the hospital or result in jail time.
Example source: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
From the AMA guidelines:
Physician or other qualified health care professional time includes the following activities, when performed:
■ preparing to see the patient (eg, review of tests)
■ obtaining and/or reviewing separately obtained history
■ performing a medically appropriate examination and/or evaluation
■ counseling and educating the patient/family/caregiver
■ ordering medications, tests, or procedures
■ referring and communicating with other health care professionals (when not separately reported)
■ documenting clinical information in the electronic or other health record
■ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
■ care coordination (not separately reported)
Well, shit. Now I feel like an idiot. Thank you for the correction, I apologize I must have missed your first comment. I threw in a link to your comment in the original, hopefully it will help to provide context.
Again don't really blame you - based off of the issues we have with insurance it often seems like the people on the other side didn't really have correct training. That actually being the case seems like the kinda thing that would be by design.
Depending on how long ago this was it could also just be process changes. As I get older I get more worried about these, times when you find out Pluto isn't a fucking planet anymore.
If you are lucky someone tells you at a reasonable time but it's all too easy to get left behind.
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