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A patienT wants solutions; at least, he wants attentiveness. He is preoccupied with the failings of his life.

But I’m preoccupied, too: with counting. If I document one element of his family or social history in the electronic medical record, it’s considered “pertinent,” but two “established elements” — or three “new elements” — are “complete,” and worth more. One-to-five findings on the psychiatric exam are “problem-focused,” but if there are six, the exam becomes “expanded problem focused,” which is also worth more. Reviewing old records is two data points, but reviewing lab tests is only one. Counting, counting.

These numbers add up to a billing code; these billing codes add up to Medicare reimbursement. You combine history complexity plus examination bullets plus medical decision-making plus risk, and out of the confusion an accurate code is supposed to pop clearly into view.


There’s a crib sheet on a corner of the desk: a list of key components of the Current Procedural Terminology codes. It’s a bookie’s scorecard, the Mahjong rules, our little life preserver for land use. It’s covered with numbers, points, and descriptions; the condensation of hundreds of pages of formulas that AMA committees have hammered out over vats of coffee, and probably pints of blood.

Using it feels like spinning the great wheel of chance and seeing what prize money it lands on — except, of course, that this is very precise science. My hands are typing, and I’m adding, subtracting, worrying, re-adding. The patient is still talking, last time I checked.

Auditors will be using these same formulas to check the charts for Medicare fraud. We cannot wish CPT codes away. Most of us have gone to training sessions, downloaded forests of manuals, and followed thousands of arguments on list-serves, in the effort to make them simple. Still, there is confusion, disagreement, and highly educated sweat leaking onto keyboards across the nation, because these formulas are not simple, and, really, not even very useful.


As a result, a sense of fervent, desperate distractedness accompanies listening, now. If I were a patient, I would worry about my worth.

Elissa Ely is a psychiatrist.