Artifiicial Stupidity

A few weeks ago I posted a sample of ChatGPT output, specifically a (very lame) fairy tale. What I didn't discuss here, as far as I remember, was that I later asked it some fairly technical questions in my academic specialty and it answered them accurately enough that a student would definitely get full credit on an exam. The New England Journal of Medicine today has launched what will be a series of articles on so-called Artificial Intelligence in medicine, beginning with ChatGPT and its competitors. 

Unfortunately it's paywalled, but I will just tell you that ChatGPT can pass the U.S. Medical Licensing Examination with a commendable score, produce accurate notes of a clinical encounter from an audio recording, and provide accurate specialty consultation. It doesn't seem there have been formal studies, but it appears to be no more fallible than a human physician, although its proponents do insist that human experts still need to review its output. 

You may have read or heard about the open letter with 1,000 signatories (of whom for some mysterious reason the NYT singled out Elon Musk, who they apparently regard as the world's most perspicacious human) call for a moratorium in the development of chatbots, seeing potential grave dangers to society. They may be right but history since the 19th Century has made it clear that you can't put the technological genie back in the bottle. Actually, I would say history since the neolithic revolution tells us that. People will inevitably grab hold of technologies for the immediate apparent rewards, but we only find out later what the harms may be, and by then the technology is so deeply embedded that we don't have a way out -- this goes for everything from agriculture to the automobile. 

 

The only reason there is hope to free ourselves from fossil fuels is that there are alternative technologies that can achieve pretty much the same results. But we aren't talking about giving up our cars and our electric lights and our factories, we're just talking about powering them differently. It does seem to me that once AI is embedded in processes that have hitherto been reliant on the 3 pounds of gray goo in our heads, it will be pretty much impossible to get it out. 

I think the most dystopian visions are at most highly improbable. The science fiction writer Dan Simmons, [Spoiler alert -- you don't really figure this out until near the end . . . ] in the Hyperion tetralogy, envisioned as long ago as 1989 a far future in which an artificial intelligence ecosystem had escaped from human control and come to exploit humanity for its own ends. (He also envisioned that human descendants from the even farther future would send a messiah to free humanity from its oppression, but that's probably not relevant here.) People do worry about something like this happening concretely, in the fairly near future. I don't find that plausible with existing technology, because these entities have no goals or desires of their own. They don't want anything, they don't want to control anything, they're purely reactive. But who knows, somebody might create a goal directed bot that does get out of control, before we can pull the plug. 

 

But of more concern is how these technologies will affect social relations, employment, and the information environment. Beyond putting physicians out of work, they could  be exploited to deceive and manipulate, and could unintentionally restructure society in ways we can't predict or even conceive. I don't know how alarmed we ought to be, but we do need to be paying attention.

Wednesday Bible Study: The priests clean up

Basically, Chapter 31 is about how the people donate immense amounts of loot to the priests, which is of course a good thing in the eyes of the Lord. As usual, the Chronicler is also very interested in lists of names and genealogies, which would seem to be of no interest whatsoever a century or more later when he actually wrote this but we all have our obsessions. 

BTW the Asherah poles mentioned in the first verse are shrines to a goddess who, according to an account I recently read, scholars believe was originally Yahweh's wife or consort. So this history of going back and forth with putting up the Asherah poles and then removing them, which we have seen throughout the Deuteronomistic History as well as Chronicles, would actually reflect a doctrinal dispute as to whether Yahweh is a bachelor who rules alone, or shares god duties with his girlfriend. I don't know whether this is a scholarly consensus, but it's an interesting idea.

31 When all this had ended, the Israelites who were there went out to the towns of Judah, smashed the sacred stones and cut down the Asherah poles. They destroyed the high places and the altars throughout Judah and Benjamin and in Ephraim and Manasseh. After they had destroyed all of them, the Israelites returned to their own towns and to their own property.

Contributions for Worship

² Hezekiah assigned the priests and Levites to divisions—each of them according to their duties as priests or Levites—to offer burnt offerings and fellowship offerings, to minister, to give thanks and to sing praises at the gates of the Lord’s dwelling. ³ The king contributed from his own possessions for the morning and evening burnt offerings and for the burnt offerings on the Sabbaths, at the New Moons and at the appointed festivals as written in the Law of the Lord. ⁴ He ordered the people living in Jerusalem to give the portion due the priests and Levites so they could devote themselves to the Law of the Lord. ⁵ As soon as the order went out, the Israelites generously gave the firstfruits of their grain, new wine, olive oil and honey and all that the fields produced. They brought a great amount, a tithe of everything. ⁶ The people of Israel and Judah who lived in the towns of Judah also brought a tithe of their herds and flocks and a tithe of the holy things dedicated to the Lord their God, and they piled them in heaps. ⁷ They began doing this in the third month and finished in the seventh month. ⁸ When Hezekiah and his officials came and saw the heaps, they praised the Lord and blessed his people Israel.

⁹ Hezekiah asked the priests and Levites about the heaps; ¹⁰ and Azariah the chief priest, from the family of Zadok, answered, “Since the people began to bring their contributions to the temple of the Lord, we have had enough to eat and plenty to spare, because the Lord has blessed his people, and this great amount is left over.”

¹¹ Hezekiah gave orders to prepare storerooms in the temple of the Lord, and this was done. ¹² Then they faithfully brought in the contributions, tithes and dedicated gifts. Konaniah, a Levite, was the overseer in charge of these things, and his brother Shimei was next in rank. ¹³ Jehiel, Azaziah, Nahath, Asahel, Jerimoth, Jozabad, Eliel, Ismakiah, Mahath and Benaiah were assistants of Konaniah and Shimei his brother. All these served by appointment of King Hezekiah and Azariah the official in charge of the temple of God.

¹⁴ Kore son of Imnah the Levite, keeper of the East Gate, was in charge of the freewill offerings given to God, distributing the contributions made to the Lord and also the consecrated gifts. ¹⁵ Eden, Miniamin, Jeshua, Shemaiah, Amariah and Shekaniah assisted him faithfully in the towns of the priests, distributing to their fellow priests according to their divisions, old and young alike.

¹⁶ In addition, they distributed to the males three years old or more whose names were in the genealogical records—all who would enter the temple of the Lord to perform the daily duties of their various tasks, according to their responsibilities and their divisions. ¹⁷ And they distributed to the priests enrolled by their families in the genealogical records and likewise to the Levites twenty years old or more, according to their responsibilities and their divisions. ¹⁸ They included all the little ones, the wives, and the sons and daughters of the whole community listed in these genealogical records. For they were faithful in consecrating themselves.

¹⁹ As for the priests, the descendants of Aaron, who lived on the farmlands around their towns or in any other towns, men were designated by name to distribute portions to every male among them and to all who were recorded in the genealogies of the Levites.

²⁰ This is what Hezekiah did throughout Judah, doing what was good and right and faithful before the Lord his God. ²¹ In everything that he undertook in the service of God’s temple and in obedience to the law and the commands, he sought his God and worked wholeheartedly. And so he prospered.

Murderous capitalism

This essay by Hunter is mostly a summary of a Washington Post story but I'm sending you there because of the WaPo paywall. It's rather long-winded and repetitive -- you'll pretty much get the idea before you read to the end.  To put it in a coconut shell, the first main point is that the only purpose of AR-15 rifles and knockoffs thereof is to kill humans. They are military rifles that can get off a lot of not particularly well-aimed shots quickly and that cause horrendous tissue damage. They are not useful for hunting or target shooting or any other conceivable "sport." They are military weapons designed to kill lots of people before they can kill you. That's all they are good for.

The reason so many people buy them is because of marketing by the companies that make them. The only way to get people to want to buy a product the only purpose of which is to kill large numbers of humans in a short time is to make people believe that is something they may have a reason to do. As Hunter summarizes it:

The National Rifle Association [which represents firearm manufacturers, not owners] founded its case for the AR-15 and other military-styled rifles not on the invention of some new sport, but on overt bigotry, racism, and paranoia. NRA CEO Wayne LaPierre was insistent upon it. The magazines leaned heavily on courting a specific new kind of gun owner, one whose need for self-defense had escalated from needing to defend against a lone burglar to needing to defend against:

• Organized terrorist attacks in or near your neighborhood

• "Urban" looters invading your town en masse after a natural disaster or "race riots"

• The United States government itself.

Each of these scenarios was presented to gun owners as a reason that a mere handgun or hunting rifle could no longer be called adequate self-defense. It was not that American gun owners might need to defend themselves against individual criminals; the new standard became the perceived ability to "win" in an armed standoff against dozens of attackers.

 

Practitioners of the pseudo-science called economics claim that consumers are "sovereign," that the Free Market™ gives consumers the power to maximize their "utility" by exercising "choice" in the allocation of their resources. In fact the most destructive epidemic in U.S. history, the tobacco epidemic, was caused by capitalists who convinced young people that smoking cigarettes would make them cool, sexy, manly (and later womanly, if they picked the right brand of cancer stick), and that claims that it would cause them to die horribly were fake science. In fact, they knew it was true for decades and they funded their own fake scientists to try to obfuscate the truth. What kind of person does that, and goes home to their family at night? 

The same happened with sugar, and lead, and while fossil fuels didn't really need marketing to become popular,there's still a long history of marketing and science denial and all sorts of perfidy that caused us to burn a whole lot more of them than we needed to and has us stuck in a very hard predicament trying to stop. Credit the WaPo for exposing this particular brand of murderous bullshit, but there's plenty more out there.

Sunday Sermonette: Something got passed over

In Ch. 30, Hezekiah restores observance of the Passover. Just to be clear, while Passover in Rabbinical Judaism is observed in the home, the original version included sacrifices at the altar, specifically of barley and a lamb. So okay. There are a couple of details about this that are a little off from the original instructions in Exodus, but that's no biggie. 

 

However,this is in direct contradiction to the Book of Kings, in which Josiah restores the Passover three generations later. To quote from 2 Kings 23:

 

²¹ And the king [Josiah] commanded all the people, saying, Keep the passover unto the LORD your God, as it is written in the book of this covenant.

²² Surely there was not holden such a passover from the days of the judges that judged Israel, nor in all the days of the kings of Israel, nor of the kings of Judah;

²³ But in the eighteenth year of king Josiah, wherein this passover was holden to the LORD in Jerusalem.

 

Kings mentions Hezekiah only briefly, and omits this story entirely and in fact contradicts it. But  Hez is a major figure in Chronicles.  Since the original version of the Book of Kings was commissioned by Josiah (it was later amended during the Babylonian exile) that presumably explains why Josiah gets credit for all the stuff Hezekiah does in Chronicles.But that also implies that the Chronicler had an earlier source for all this, which has been lost.

As for banning the Bible from school libraries, obviously I am not in favor of it. Some people have a missing sarcasm detector.

30 Hezekiah sent word to all Israel and Judah and also wrote letters to Ephraim and Manasseh, inviting them to come to the temple of the Lord in Jerusalem and celebrate the Passover to the Lord, the God of Israel. ² The king and his officials and the whole assembly in Jerusalem decided to celebrate the Passover in the second month. ³ They had not been able to celebrate it at the regular time because not enough priests had consecrated themselves and the people had not assembled in Jerusalem. ⁴ The plan seemed right both to the king and to the whole assembly. ⁵ They decided to send a proclamation throughout Israel, from Beersheba to Dan, calling the people to come to Jerusalem and celebrate the Passover to the Lord, the God of Israel. It had not been celebrated in large numbers according to what was written.

⁶ At the king’s command, couriers went throughout Israel and Judah with letters from the king and from his officials, which read:

“People of Israel, return to the Lord, the God of Abraham, Isaac and Israel, that he may return to you who are left, who have escaped from the hand of the kings of Assyria. ⁷ Do not be like your parents and your fellow Israelites, who were unfaithful to the Lord, the God of their ancestors, so that he made them an object of horror, as you see. ⁸ Do not be stiff-necked, as your ancestors were; submit to the Lord. Come to his sanctuary, which he has consecrated forever. Serve the Lord your God, so that his fierce anger will turn away from you. ⁹ If you return to the Lord, then your fellow Israelites and your children will be shown compassion by their captors and will return to this land, for the Lord your God is gracious and compassionate. He will not turn his face from you if you return to him.”

¹⁰ The couriers went from town to town in Ephraim and Manasseh, as far as Zebulun, but people scorned and ridiculed them. ¹¹ Nevertheless, some from Asher, Manasseh and Zebulun humbled themselves and went to Jerusalem. ¹² Also in Judah the hand of God was on the people to give them unity of mind to carry out what the king and his officials had ordered, following the word of the Lord.

¹³ A very large crowd of people assembled in Jerusalem to celebrate the Festival of Unleavened Bread in the second month. ¹⁴ They removed the altars in Jerusalem and cleared away the incense altars and threw them into the Kidron Valley.

¹⁵ They slaughtered the Passover lamb on the fourteenth day of the second month. The priests and the Levites were ashamed and consecrated themselves and brought burnt offerings to the temple of the Lord. ¹⁶ Then they took up their regular positions as prescribed in the Law of Moses the man of God. The priests splashed against the altar the blood handed to them by the Levites. ¹⁷ Since many in the crowd had not consecrated themselves, the Levites had to kill the Passover lambs for all those who were not ceremonially clean and could not consecrate their lambs^[a] to the Lord. ¹⁸ Although most of the many people who came from Ephraim, Manasseh, Issachar and Zebulun had not purified themselves, yet they ate the Passover, contrary to what was written. But Hezekiah prayed for them, saying, “May the Lord, who is good, pardon everyone ¹⁹ who sets their heart on seeking God—the Lord, the God of their ancestors—even if they are not clean according to the rules of the sanctuary.” ²⁰ And the Lord heard Hezekiah and healed the people.

²¹ The Israelites who were present in Jerusalem celebrated the Festival of Unleavened Bread for seven days with great rejoicing, while the Levites and priests praised the Lord every day with resounding instruments dedicated to the Lord.^[b]

²² Hezekiah spoke encouragingly to all the Levites, who showed good understanding of the service of the Lord. For the seven days they ate their assigned portion and offered fellowship offerings and praised^[c] the Lord, the God of their ancestors.

²³ The whole assembly then agreed to celebrate the festival seven more days; so for another seven days they celebrated joyfully. ²⁴ Hezekiah king of Judah provided a thousand bulls and seven thousand sheep and goats for the assembly, and the officials provided them with a thousand bulls and ten thousand sheep and goats. A great number of priests consecrated themselves. ²⁵ The entire assembly of Judah rejoiced, along with the priests and Levites and all who had assembled from Israel, including the foreigners who had come from Israel and also those who resided in Judah. ²⁶ There was great joy in Jerusalem, for since the days of Solomon son of David king of Israel there had been nothing like this in Jerusalem. ²⁷ The priests and the Levites stood to bless the people, and God heard them, for their prayer reached heaven, his holy dwelling place.

Footnotes

1. 2 Chronicles 30:17 Or consecrate themselves
2. 2 Chronicles 30:21 Or priests sang to the Lord every day, accompanied by the Lord’s instruments of praise
3. 2 Chronicles 30:22 Or and confessed their sins to

 

Hey indeedy

Utah is among the many states that are now encouraging parents to ban books from school libraries. Well, a parent has exercised the right to request banning what is one of the most indecent books there is, the Bible. We've been reading it here, blithely enjoying the multiple accounts of incest, rape, and seduction. Consider just a single character, Judah, the guy after whom the Jewish people are named and supposedly an ancestor of Joseph, husband of Mary:

Judah marries the daughter of Shua, a Canaanite. Genesis chapter 38 Judah and his wife have three children, Er, Onan, and Shelah. Er marries Tamar, but God kills him because he was wicked in His sight (Gen. 38:7). Tamar becomes Onan's wife in accordance with custom, but he too is killed after he refuses to father children for his older brother's childless widow, and spills his seed instead.^[5] Although Tamar should have married Shelah, the remaining brother, Judah did not consent, and in response Tamar deceives Judah into having intercourse with her by pretending to be a prostitute. When Judah discovers that Tamar is pregnant he prepares to have her killed, but recants and confesses when he finds out that he is the father (Gen. 38:24-26).^[6] Tamar is the mother of twins, Perez (Peretz) and Zerah (Gen. 38:27-30). The former is the patrilinear ancestor of the messiah, according to the Book of Ruth (4:18-22).  . . . . 

Judah's position is further enhanced through the downfall of his older brothers: Reuben, the eldest, cedes his birthright through sexual misconduct with Jacob's concubine Bilhah (Gen. 35:22), and the bloody revenge taken by Simeon and Levi following the rape of Dinah (Gen. chap. 34)^[16] disqualifies them as leaders.^[17]

 

Of course his descendant David raped Baathsheba and murdered her husband. Lot's daughters seduced him in order to get pregnant. Delilah seduced Samson and betrayed him to the Philistines. We could of course go on endlessly. It's just filth. Get it out of our schools.

Wednesday Bible Study: Cleanup on aisle 9

Chapter 29 is an extremely long winded way of saying that when Hezekiah became king, he repaired and restored the Temple, and removed stuff that shouldn't have been there, and restored the sacrifices to Yahweh. In the previous chapter, king Azah had established shrines to other gods and engaged in alien rites, but it doesn't mention anything about the Temple. 2 Kings 18 has a much briefer account of Hezekiah destroying Azah's shrines to other gods and quite bizarrely destroying a brass serpent that Moses had made (Numbers 21:9) which has not been mentioned since. That Yahweh had ordered Moses to make a graven image in the first place is incongruous, but that Hezekiah restores orthodoxy by finally destroying it seems even weirder. Anyway, Kings doesn't mention anything about restoring and cleansing the Temple either so this is entirely unique to Chronicles. The source is unknown. 

Just for yucks, here's the passage from Numbers. (KJV, again just for yucks):

⁵ And the people spake against God, and against Moses, Wherefore have ye brought us up out of Egypt to die in the wilderness? for there is no bread, neither is there any water; and our soul loatheth this light bread.

The people spoke against God and Moses, saying,

Why did you make us leave Egypt to die in the wilderness?

There is no bread or water, and we hate this light bread. [3]

⁶ And the LORD sent fiery serpents among the people, and they bit the people; and much people of Israel died.

God sent fiery serpents to bite the people. And many died. [4]

⁷ Therefore the people came to Moses, and said, We have sinned, for we have spoken against the LORD, and against thee; pray unto the LORD, that he take away the serpents from us. And Moses prayed for the people.

The people came to Moses, and said,

We have sinned by criticizing you and God.

Ask God to take away the serpents.

And Moses prayed for the people.

God tells Moses to make a fiery serpent

⁸ And the LORD said unto Moses, Make thee a fiery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live.

⁹ And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived.

Anyway, this was evidently a mistake, Yahweh made an oops, which gets corrected in Kings but goes unmentioned here.

29 Hezekiah was twenty-five years old when he became king, and he reigned in Jerusalem twenty-nine years. His mother’s name was Abijah daughter of Zechariah. ² He did what was right in the eyes of the Lord, just as his father David had done.

³ In the first month of the first year of his reign, he opened the doors of the temple of the Lord and repaired them. ⁴ He brought in the priests and the Levites, assembled them in the square on the east side ⁵ and said: “Listen to me, Levites! Consecrate yourselves now and consecrate the temple of the Lord, the God of your ancestors. Remove all defilement from the sanctuary. ⁶ Our parents were unfaithful; they did evil in the eyes of the Lord our God and forsook him. They turned their faces away from the Lord’s dwelling place and turned their backs on him. ⁷ They also shut the doors of the portico and put out the lamps. They did not burn incense or present any burnt offerings at the sanctuary to the God of Israel. ⁸ Therefore, the anger of the Lord has fallen on Judah and Jerusalem; he has made them an object of dread and horror and scorn, as you can see with your own eyes. ⁹ This is why our fathers have fallen by the sword and why our sons and daughters and our wives are in captivity. ¹⁰ Now I intend to make a covenant with the Lord, the God of Israel, so that his fierce anger will turn away from us. ¹¹ My sons, do not be negligent now, for the Lord has chosen you to stand before him and serve him, to minister before him and to burn incense.”

¹² Then these Levites set to work:

from the Kohathites,

Mahath son of Amasai and Joel son of Azariah;

from the Merarites,

Kish son of Abdi and Azariah son of Jehallelel;

from the Gershonites,

Joah son of Zimmah and Eden son of Joah;

¹³ from the descendants of Elizaphan,

Shimri and Jeiel;

from the descendants of Asaph,

Zechariah and Mattaniah;

¹⁴ from the descendants of Heman,

Jehiel and Shimei;

from the descendants of Jeduthun,

Shemaiah and Uzziel.

¹⁵ When they had assembled their fellow Levites and consecrated themselves, they went in to purify the temple of the Lord, as the king had ordered, following the word of the Lord. ¹⁶ The priests went into the sanctuary of the Lord to purify it. They brought out to the courtyard of the Lord’s temple everything unclean that they found in the temple of the Lord. The Levites took it and carried it out to the Kidron Valley. ¹⁷ They began the consecration on the first day of the first month, and by the eighth day of the month they reached the portico of the Lord. For eight more days they consecrated the temple of the Lord itself, finishing on the sixteenth day of the first month.

¹⁸ Then they went in to King Hezekiah and reported: “We have purified the entire temple of the Lord, the altar of burnt offering with all its utensils, and the table for setting out the consecrated bread, with all its articles. ¹⁹ We have prepared and consecrated all the articles that King Ahaz removed in his unfaithfulness while he was king. They are now in front of the Lord’s altar.”

²⁰ Early the next morning King Hezekiah gathered the city officials together and went up to the temple of the Lord. ²¹ They brought seven bulls, seven rams, seven male lambs and seven male goats as a sin offering^[a] for the kingdom, for the sanctuary and for Judah. The king commanded the priests, the descendants of Aaron, to offer these on the altar of the Lord. ²² So they slaughtered the bulls, and the priests took the blood and splashed it against the altar; next they slaughtered the rams and splashed their blood against the altar; then they slaughtered the lambs and splashed their blood against the altar. ²³ The goats for the sin offering were brought before the king and the assembly, and they laid their hands on them. ²⁴ The priests then slaughtered the goats and presented their blood on the altar for a sin offering to atone for all Israel, because the king had ordered the burnt offering and the sin offering for all Israel.

²⁵ He stationed the Levites in the temple of the Lord with cymbals, harps and lyres in the way prescribed by David and Gad the king’s seer and Nathan the prophet; this was commanded by the Lord through his prophets. ²⁶ So the Levites stood ready with David’s instruments, and the priests with their trumpets.

²⁷ Hezekiah gave the order to sacrifice the burnt offering on the altar. As the offering began, singing to the Lord began also, accompanied by trumpets and the instruments of David king of Israel. ²⁸ The whole assembly bowed in worship, while the musicians played and the trumpets sounded. All this continued until the sacrifice of the burnt offering was completed.

²⁹ When the offerings were finished, the king and everyone present with him knelt down and worshiped. ³⁰ King Hezekiah and his officials ordered the Levites to praise the Lord with the words of David and of Asaph the seer. So they sang praises with gladness and bowed down and worshiped.

³¹ Then Hezekiah said, “You have now dedicated yourselves to the Lord. Come and bring sacrifices and thank offerings to the temple of the Lord.” So the assembly brought sacrifices and thank offerings, and all whose hearts were willing brought burnt offerings.

³² The number of burnt offerings the assembly brought was seventy bulls, a hundred rams and two hundred male lambs—all of them for burnt offerings to the Lord. ³³ The animals consecrated as sacrifices amounted to six hundred bulls and three thousand sheep and goats. ³⁴ The priests, however, were too few to skin all the burnt offerings; so their relatives the Levites helped them until the task was finished and until other priests had been consecrated, for the Levites had been more conscientious in consecrating themselves than the priests had been. ³⁵ There were burnt offerings in abundance, together with the fat of the fellowship offerings and the drink offerings that accompanied the burnt offerings.

So the service of the temple of the Lord was reestablished. ³⁶ Hezekiah and all the people rejoiced at what God had brought about for his people, because it was done so quickly.

Footnotes

1. 2 Chronicles 29:21 Or purification offering; also in verses 23 and 24

Why does health care cost so much in the U.S. part the infinity

I'm on a lot of email lists thanks to my profession. A message I got today is below. I won't make you read it before I explain that one reason medical services cost so much in this godforsaken country is that providers have to hire people to with specialized training and pay them salaries to deal with this crap. Keep in mind that they see people with multiple different kinds of insurance and they need to keep track of what insurance the person has, what it will pay for, how much, and how, based on manuals containing hundreds of pages of similar dreck. And if they don't get it just right, they won't be paid. In civilized countries, this doesn't happen.

When billing CPT code 99292 when you deliver critical care as a split (or shared) visit, an important correction has been made by the Centers for Medicare and Medicaid Services effective March 3, 2023.

According to Section 30.6.12.5 in the Medicare Claims Processing (MCP) Manual (Chapter 12), CMS changed the number of cumulative total minutes from 75 to 104.

This correction made to the MCP is effective 01/01/2023 and implemented 03/03/2023.  Please share this information to you coding, auditing and billing professionals.

“…. To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 104 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.

The same documentation rules apply for split (or shared) critical care visits as for other types of split (or shared) E/M visits. Consistent with all split/shared visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.”

MCP Chapter 12 Section 30.6.12.8 provides guidance on critical care documentation requirements.  This section was last updated in 2022, however, reviewing this information will assist in coding, documentation and billing compliance.  A few salient points to remember are:

• Critical care is a time-based service;

• Practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner;

• Documentation needs to indicate that the services furnished to the patient, including:
  • any concurrent care by the practitioner;
  • documentation of medical necessity for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member

• Services must be sufficiently documented to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient) upon audit

When critical care services are reported the same date as another E/M visit, the medical record documentation must support:

1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care,

2) that the services were medically necessary, and

3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later on that date.

• Access Transmittal 11828 for more information
• Download the MCP Manual, Chapter 12 and reference 30.6.12.5 Split/Shared Critical Care Visits

March 20, 2023

Correction of Split/Shared Critical Care CMS Billing Requirement

Documentation & Billing Compliance Update

Sunday Sermonette: Worst apostasy ever

The story of Ahaz is told in 2 Kings 16. Although the facts largely overlap, it's a completely different version of the story. It's basically the same old idea -- Ahaz forsakes Yahweh, worships Baal, and Judah gets trashed. Somewhat unusually, one of the instruments of the trashing is the northern kingdom. However, a prophet persuades the "people of Israel," oddly without mentioning their king or leadership, to release the Judean captives, essentially on the grounds that they have no right to enslave fellow Israelites.

Ahaz goes on to humiliate Judah before the Syrian king Tiglath-Pileser, by bribing him with some of the temple treasures and worshiping the Assyrian gods. He doesn't seem to suffer any consequences for this, however. Even though it's said to make God angry, God doesn't actually do anything about it. The reference in verse 3, "he sacrificed his children in the fire" is an issue that has come up before in the Deuteroomistic history. There is no evidence, archaeological or documentary, of human sacrifice anywhere in the Levant. This is probably either a reference to a purification ritual, or a slander.

28 Ahaz was twenty years old when he became king, and he reigned in Jerusalem sixteen years. Unlike David his father, he did not do what was right in the eyes of the Lord. ² He followed the ways of the kings of Israel and also made idols for worshiping the Baals. ³ He burned sacrifices in the Valley of Ben Hinnom and sacrificed his children in the fire, engaging in the detestable practices of the nations the Lord had driven out before the Israelites. ⁴ He offered sacrifices and burned incense at the high places, on the hilltops and under every spreading tree.

⁵ Therefore the Lord his God delivered him into the hands of the king of Aram. The Arameans defeated him and took many of his people as prisoners and brought them to Damascus.

He was also given into the hands of the king of Israel, who inflicted heavy casualties on him. ⁶ In one day Pekah son of Remaliah killed a hundred and twenty thousand soldiers in Judah—because Judah had forsaken the Lord, the God of their ancestors. ⁷ Zikri, an Ephraimite warrior, killed Maaseiah the king’s son, Azrikam the officer in charge of the palace, and Elkanah, second to the king. ⁸ The men of Israel took captive from their fellow Israelites who were from Judah two hundred thousand wives, sons and daughters. They also took a great deal of plunder, which they carried back to Samaria.

⁹ But a prophet of the Lord named Oded was there, and he went out to meet the army when it returned to Samaria. He said to them, “Because the Lord, the God of your ancestors, was angry with Judah, he gave them into your hand. But you have slaughtered them in a rage that reaches to heaven. ¹⁰ And now you intend to make the men and women of Judah and Jerusalem your slaves. But aren’t you also guilty of sins against the Lord your God? ¹¹ Now listen to me! Send back your fellow Israelites you have taken as prisoners, for the Lord’s fierce anger rests on you.”

¹² Then some of the leaders in Ephraim—Azariah son of Jehohanan, Berekiah son of Meshillemoth, Jehizkiah son of Shallum, and Amasa son of Hadlai—confronted those who were arriving from the war. ¹³ “You must not bring those prisoners here,” they said, “or we will be guilty before the Lord. Do you intend to add to our sin and guilt? For our guilt is already great, and his fierce anger rests on Israel.”

¹⁴ So the soldiers gave up the prisoners and plunder in the presence of the officials and all the assembly. ¹⁵ The men designated by name took the prisoners, and from the plunder they clothed all who were naked. They provided them with clothes and sandals, food and drink, and healing balm. All those who were weak they put on donkeys. So they took them back to their fellow Israelites at Jericho, the City of Palms, and returned to Samaria.

¹⁶ At that time King Ahaz sent to the kings^[a] of Assyria for help. ¹⁷ The Edomites had again come and attacked Judah and carried away prisoners, ¹⁸ while the Philistines had raided towns in the foothills and in the Negev of Judah. They captured and occupied Beth Shemesh, Aijalon and Gederoth, as well as Soko, Timnah and Gimzo, with their surrounding villages. ¹⁹ The Lord had humbled Judah because of Ahaz king of Israel,^[b] for he had promoted wickedness in Judah and had been most unfaithful to the Lord. ²⁰ Tiglath-Pileser^[c] king of Assyria came to him, but he gave him trouble instead of help. ²¹ Ahaz took some of the things from the temple of the Lord and from the royal palace and from the officials and presented them to the king of Assyria, but that did not help him.

²² In his time of trouble King Ahaz became even more unfaithful to the Lord. ²³ He offered sacrifices to the gods of Damascus, who had defeated him; for he thought, “Since the gods of the kings of Aram have helped them, I will sacrifice to them so they will help me.” But they were his downfall and the downfall of all Israel.

²⁴ Ahaz gathered together the furnishings from the temple of God and cut them in pieces. He shut the doors of the Lord’s temple and set up altars at every street corner in Jerusalem. ²⁵ In every town in Judah he built high places to burn sacrifices to other gods and aroused the anger of the Lord, the God of his ancestors.

²⁶ The other events of his reign and all his ways, from beginning to end, are written in the book of the kings of Judah and Israel. ²⁷ Ahaz rested with his ancestors and was buried in the city of Jerusalem, but he was not placed in the tombs of the kings of Israel. And Hezekiah his son succeeded him as king.

Footnotes

1. 2 Chronicles 28:16 Most Hebrew manuscripts; one Hebrew manuscript, Septuagint and Vulgate (see also 2 Kings 16:7) king
2. 2 Chronicles 28:19 That is, Judah, as frequently in 2 Chronicles
3. 2 Chronicles 28:20 Hebrew Tilgath-Pilneser, a variant of Tiglath-Pileser

Platinum Anniversary

As some readers know, for many years I maintained the Today in Iraq blog, during the U.S. occupation. The invasion of Iraq was an illegal war of aggression, and U.S. troops and mercenaries committed innumerable war crimes. The result was an indescribable catastrophe for Iraqis, with a conservative death toll estimate of 800,000 and most likely far higher, at least as many people injured, and entire cities destroyed. (Notably Fallujah and Mosul.) 

The consequences for the U.S. were not as dire, but $8 trillion wasted and immense damage to the nation's international standing, along with 4,400 military dead and 32,000 wounded. (Mercenaries who were killed were often labeled by the corporate media as "civilian reconstruction workers," btw.) Alissa Rubin in the NYT gives an in-depth update on Iraq today. The country does have an independent press, and it has elections of a sort, but the result is not anything resembling democracy. The country is run by corruption and theft.  Most people live in poverty and squalor, despite the country's oil wealth it is economically backward, and there is no safety or security.

We're still arguing about why the U.S., along with Britain, invaded in the first place. Bush, Cheney, Powell and Blair ginned up a campaign of blatant lies to make it happen, that the corporate media swallowed without even chewing. A leading theory is that the real target was Iran. With the U.S. already occupying Afghanistan, by occupying Iraq we'd have them surrounded. Of course the exact opposite happened and Iran is now a dominant power in Iraq outside of Kurdistan, and occupies the country with Shiite militias loyal to Iranian leaders. 

The architects of this atrocity, and the vast ranks of their cheerleaders in politics and journalism, have paid no price at all. I do think some of them are chastened a bit -- reporters seem to be more skeptical of official claims, and the country as a whole no longer gets enthusiastic about military adventures. On the other hand that was true after Vietnam but it was soon forgotten, and neither disaster stopped the military industrial complex from continuing to bloat without apparent end or limit. 

 

When will they ever learn.

Death in Childbirth

I taught a course last year in global maternal mortality so I have some idea of what I'm talking about here. Childbirth is dangerous for women because, for one thing, thanks to evolution giving us big brains, the baby's head is too big for the birth canal. However, there are other complications of pregnancy that can occur. In Europe in the 19th Century, as it became common for women to give birth in hospitals, infectious disease killed a lot of mothers, thanks to the doctors transferring pathogens on their unwashed hands and unsterile instruments. Many a family was bereaved by maternal death, but it has become rare in most of the wealthy countries today. With, as I expect you have already guessed, one exception.

Maternal mortality in the U.S. has long been far more common here than in comparable nations, and this has in large part been due to a huge racial disparity. Black women are much more likely to die in childbirth than white women. But now it's gotten worse. I'm just going to post a press release I got this morning, and let it speak for itself.

Shocking Rise in Maternal Mortality, With Black Moms at Greatest Risk, Underscores Need for Congress to Pass Momnibus Act and Secure Access to Abortion Care

 

FOR IMMEDIATE RELEASE

March 17, 2023

CONTACT: Magen Eissenstat, 202/371-1996

 

Statement of leaders of MomsRising, the online and on-the-ground organization of more than one million mothers and their families, on the National Center for Health Statistics data released yesterday, showing a dramatic rise in maternal mortality and disparities in the United States in 2021:

 

“This is an emergency. Too many moms are losing their lives during pregnancy and childbirth in this country. Our nation’s maternal health crisis got appreciably worse in 2021, with huge disparities and Black women suffering the worst outcomes. Data released yesterday by the National Center for Health Statistics/Centers for Disease Control and Prevention shows that 1,205 women died of maternal causes in the United States in 2021, up sharply from 861 in 2020 and 754 in 2019. (Those deaths are among women who were pregnant or had been pregnant within the last 42 days, from any cause related to or aggravated by the pregnancy or its management.) The maternal mortality rate for non-Hispanic Black women was 2.6 times the rate for non-Hispanic white women.

 

“It is appalling that our already-high maternal mortality rate is getting worse, as are the disparities. It’s long past time lawmakers recognize this as the emergency that it is. The Black Maternal Health Momnibus Act will soon be reintroduced in both chambers of Congress, and its passage should be an immediate priority so we can provide more funds to strengthen federal maternal health programs, address social determinants of health, support diversification of the perinatal health workforce, provide grants to improve maternal mental health, support anti-bias trainings for health care professionals, and more.”

 

-Statement of Monifa Bandele, Chief Strategy Officer, MomsRising

 

“Certainly COVID is part of the reason maternal health outcomes in the United States worsened in 2021, but we had the highest maternal mortality rate of any industrialized nation before the pandemic struck. Enactment of the Black Maternal Health Momnibus Act, which will save lives and improve the health of mothers and babies, is long overdue.

 

“But there is more we need lawmakers to do. The shameful SCOTUS ruling in Dobbs v. Jackson Women’s Health Organization and the state abortion bans and restrictions it allowed are sure to exacerbate our already-devastating maternal health crisis. They have resulted in women being denied not just abortion care but also birth control, care for miscarriages, medications they need and have long taken, and other essential services. Low-income women and moms, women of color, young, rural and immigrant women, people with disabilities, and those who are LGBTQIA+ are suffering the most.

 

“America’s moms call on lawmakers at every level to prioritize maternal health and secure access to abortion care. Improving women’s health and addressing our maternal health crisis should be our highest priority.”

 

-Statement of Kristin Rowe-Finkbeiner, Executive Director and CEO, MomsRising

 

# # # #