The emperor (still) has no codes

The Psychiatry section of the American Medical Association’s manual on Current Procedural Terminology codes is a disaster.

In our efforts to make the transition to a medical model, we have imposed on ourselves rules that are complicated, largely irrelevant, and harmful. It is one thing to artificially separate evaluation and management (E&M) services from psychotherapy, it is even worse to dictate rules that interfere with good practice.

The criteria for E&M sessions are absurd. Start with History. Are we counting the number of elements and chronic conditions? Have we taken additional past family or medical history on an established patient? Is it necessary or relevant to do a full review of systems?

Consider the Examination criterion. We should not be doing vital signs on our patients unless specifically indicated. Same for examination of the musculoskeletal system. Psychiatry has a long, thoughtful tradition of consciously selecting when we touch our patients. My patients would be rightly appalled if I took their vital signs or examined their muscle tone at each visit.

Check out Medical Decision Making. We need problem points that allow us to decide whether symptoms are established or new, and if they are getting worse. We need data points, so we will have to order lab tests. Particularly with an established patient, how many times can we order labs or obtain old records? A little creativity might be in order here.

How about the Table of Risk? What if the patient has an acute illness that does not have systemic symptoms or pose a threat to life or bodily function? Then our patient is automatically at low risk and denied even a "moderate" 25-minute E&M session. What if our patient doesn’t need any diagnostic procedures? More trouble.

Of course, we still must calculate the Complexity of Medical Decision Making (hoping it comes out high enough to justify our time) and decide how much time was spent counseling.

The harmful ramifications of these criteria are many. One is the insidious change in thinking that occurs as we start to count "bullets" and wish for more lab tests, instead of paying attention to and treating the patient.

Another is that these criteria are being used by managed care when auditing charts, making it almost impossible to practice correctly and still pass an audit.

Perhaps worst of all, psychiatry residents are being taught these rules as the necessary and proper way to practice. They are not being encouraged to sit and listen to the patient, to explore symptoms, to establish a therapeutic alliance, to think about dynamics, and or to be thoughtful about touching the person. These are all principles that need to be observed – even in E&M sessions.

I have been in practice for 26 years. I have served as an inpatient medical director, an outpatient psychopharmacologist and therapist, and a supervisor at a major teaching hospital. I can state categorically that if we are paying attention to and following the new CPT criteria, we are being lousy psychiatrists. We are not paying attention to patients, and we are not being flexible about their interview and treatment needs.

The profession of psychiatry has taken a huge step backward. We must continue to protest these new criteria. The American Psychiatric Association must develop flexible, user-friendly guidelines that are appropriate for practice. Our patients deserve nothing less.

Dr. Weiss is in private practice in North Andover, Mass.

The Psychiatry section of the American Medical Association’s manual on Current Procedural Terminology codes is a disaster.

In our efforts to make the transition to a medical model, we have imposed on ourselves rules that are complicated, largely irrelevant, and harmful. It is one thing to artificially separate evaluation and management (E&M) services from psychotherapy, it is even worse to dictate rules that interfere with good practice.

The criteria for E&M sessions are absurd. Start with History. Are we counting the number of elements and chronic conditions? Have we taken additional past family or medical history on an established patient? Is it necessary or relevant to do a full review of systems?

Consider the Examination criterion. We should not be doing vital signs on our patients unless specifically indicated. Same for examination of the musculoskeletal system. Psychiatry has a long, thoughtful tradition of consciously selecting when we touch our patients. My patients would be rightly appalled if I took their vital signs or examined their muscle tone at each visit.

Check out Medical Decision Making. We need problem points that allow us to decide whether symptoms are established or new, and if they are getting worse. We need data points, so we will have to order lab tests. Particularly with an established patient, how many times can we order labs or obtain old records? A little creativity might be in order here.

How about the Table of Risk? What if the patient has an acute illness that does not have systemic symptoms or pose a threat to life or bodily function? Then our patient is automatically at low risk and denied even a "moderate" 25-minute E&M session. What if our patient doesn’t need any diagnostic procedures? More trouble.

Of course, we still must calculate the Complexity of Medical Decision Making (hoping it comes out high enough to justify our time) and decide how much time was spent counseling.

The harmful ramifications of these criteria are many. One is the insidious change in thinking that occurs as we start to count "bullets" and wish for more lab tests, instead of paying attention to and treating the patient.

Another is that these criteria are being used by managed care when auditing charts, making it almost impossible to practice correctly and still pass an audit.

Perhaps worst of all, psychiatry residents are being taught these rules as the necessary and proper way to practice. They are not being encouraged to sit and listen to the patient, to explore symptoms, to establish a therapeutic alliance, to think about dynamics, and or to be thoughtful about touching the person. These are all principles that need to be observed – even in E&M sessions.

I have been in practice for 26 years. I have served as an inpatient medical director, an outpatient psychopharmacologist and therapist, and a supervisor at a major teaching hospital. I can state categorically that if we are paying attention to and following the new CPT criteria, we are being lousy psychiatrists. We are not paying attention to patients, and we are not being flexible about their interview and treatment needs.

The profession of psychiatry has taken a huge step backward. We must continue to protest these new criteria. The American Psychiatric Association must develop flexible, user-friendly guidelines that are appropriate for practice. Our patients deserve nothing less.

Dr. Weiss is in private practice in North Andover, Mass.

The Psychiatry section of the American Medical Association’s manual on Current Procedural Terminology codes is a disaster.

In our efforts to make the transition to a medical model, we have imposed on ourselves rules that are complicated, largely irrelevant, and harmful. It is one thing to artificially separate evaluation and management (E&M) services from psychotherapy, it is even worse to dictate rules that interfere with good practice.

The criteria for E&M sessions are absurd. Start with History. Are we counting the number of elements and chronic conditions? Have we taken additional past family or medical history on an established patient? Is it necessary or relevant to do a full review of systems?

Consider the Examination criterion. We should not be doing vital signs on our patients unless specifically indicated. Same for examination of the musculoskeletal system. Psychiatry has a long, thoughtful tradition of consciously selecting when we touch our patients. My patients would be rightly appalled if I took their vital signs or examined their muscle tone at each visit.

Check out Medical Decision Making. We need problem points that allow us to decide whether symptoms are established or new, and if they are getting worse. We need data points, so we will have to order lab tests. Particularly with an established patient, how many times can we order labs or obtain old records? A little creativity might be in order here.

How about the Table of Risk? What if the patient has an acute illness that does not have systemic symptoms or pose a threat to life or bodily function? Then our patient is automatically at low risk and denied even a "moderate" 25-minute E&M session. What if our patient doesn’t need any diagnostic procedures? More trouble.

Of course, we still must calculate the Complexity of Medical Decision Making (hoping it comes out high enough to justify our time) and decide how much time was spent counseling.

The harmful ramifications of these criteria are many. One is the insidious change in thinking that occurs as we start to count "bullets" and wish for more lab tests, instead of paying attention to and treating the patient.

Another is that these criteria are being used by managed care when auditing charts, making it almost impossible to practice correctly and still pass an audit.

Perhaps worst of all, psychiatry residents are being taught these rules as the necessary and proper way to practice. They are not being encouraged to sit and listen to the patient, to explore symptoms, to establish a therapeutic alliance, to think about dynamics, and or to be thoughtful about touching the person. These are all principles that need to be observed – even in E&M sessions.

I have been in practice for 26 years. I have served as an inpatient medical director, an outpatient psychopharmacologist and therapist, and a supervisor at a major teaching hospital. I can state categorically that if we are paying attention to and following the new CPT criteria, we are being lousy psychiatrists. We are not paying attention to patients, and we are not being flexible about their interview and treatment needs.

The profession of psychiatry has taken a huge step backward. We must continue to protest these new criteria. The American Psychiatric Association must develop flexible, user-friendly guidelines that are appropriate for practice. Our patients deserve nothing less.

Dr. Weiss is in private practice in North Andover, Mass.