I am writing to protest the criteria being implemented in the new CPT Evaluation and Management codes. In our transition to a medical model, we have imposed on ourselves rules for history, examination, and medical decision-making that are complicated, largely irrelevant, and harmful. It is one thing to artificially separate E&M services from psychotherapy, but it is even worse to dictate rules that necessarily interfere with good practice.
It is easy to point out the absurdity of the criteria for E&M sessions. Start with history. Are you counting the number of elements and chronic conditions? Have you 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. Are there enough bullet points? We should not be taking vital signs on our patients unless specifically indicated. The same should be considered for examination of the musculoskeletal system. Psychiatry has a long, thoughtful tradition of consciously selecting when we touch 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. You need problem points in which you decide if symptoms are established or new and if they’re worsening, and you need data points, so you’ll have to order some lab tests. Particularly with an established patient, how many times can you order labs or obtain old records? One might need to be creative 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 your patient is automatically at low risk and denied even a “moderate” 25-minute E&M session. What if your patient doesn’t need any diagnostic procedures? More trouble. Of course you must still calculate the complexity of medical decision-making (hoping it comes out high enough to justify your time) and decide how much time was spent counseling.
There are many harmful ramifications of these criteria. One is the insidious change in thinking that occurs as you 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 to be thoughtful about touching the patient. These are all principles that need to be observed, even in E&M sessions.
I have been in practice for 26 years, have been an inpatient medical director, outpatient psychopharmacologist and therapist, and I supervise residents at a major teaching hospital. I can state categorically that if you are paying attention to and following the new CPT criteria, then you are being a lousy psychiatrist. You are not paying attention to the patient and you are not being flexible about the interview and treatment needs.
In my opinion, the profession of psychiatry has taken a huge step backwards. I urge my colleagues to also protest these new criteria, and I ask the leadership of the American Psychiatric Association to develop flexible, user-friendly guidelines that are appropriate for our practice. Our patients deserve this.
Jonathan S. Weiss, MD
North Andover, Mass