Shrink Rap News

CPT, DSM, EMR, and more: Growing weary of alphabet soup


The year is not even halfway through, but I’ve figured out that 2013 is not the year of the psychiatrist. In January, we started with our first three letters: CPT. I, like many other psychiatrists, had to learn how to use the Current Procedural Terminology to bill for my services, a process that took a great deal of time and entailed rethinking about how I conduct my therapy sessions, compose my progress notes, and issue my insurance forms -- and required an investment that does nothing to improve the quality of care I render to patients. If anything, the process has worn me, as I’ve struggled to figure out how I handle a patient who is a few minutes late to a session in a landscape where 1 minute of psychotherapy makes a substantial difference in reimbursement.

I don’t participate with insurance panels, and I feel I should code in such a way that maximizes my patient's reimbursement while accurately characterizing the one of 15 possible ways to code the hour session, but I still haven’t figured out the nuances of telling a patient that because he was stuck in traffic for a few minutes, we won’t have time for the full 53 minutes of therapy after the time allotted for evaluation and management, and so I’ll need to down code and he’ll be reimbursed less for this week’s session than for last week’s.

My colleagues tell me that I’m missing great opportunities to explore these “grist for the mill” opportunities. The mill sometimes grinds me down, and instead, I sometimes sympathize with the patients’ struggles with the construction issues on my block and the parking challenges they face since a large restaurant across the street has reopened after a devastating fire last year. I run over and skip breaks between patients, grab a handful of nuts for lunch, and leave all my notes until the end of the day.

That was January. This month, we’ll see the next alphabet change when the DSM-5 unveils and clinical practice changes once again. If not clinical practice, then clinical paperwork, as I figure out what code now best captures the patients I’ve been calling “NOS,” because those particular letters have worked okay until now.

The first challenge will be to figure out exactly when the insurance companies will begin refusing claims with the old codes and when they will implement the new codes, what numbers will best substitute, and there will be yet another block of time to re-program my billing software. Okay, I admit, I’m getting faster at setting codes.

In June, I’m scheduled to begin the process of learning to use another set of alphabetic psychiatric technologies. For 2 days next month, I will be out of the clinic and into the classroom to learn the latest and greatest in doctor must-dos: the EMR – the Electronic Medical Record – and more alphabetically specific, EPIC. I don’t know what EPIC stands for, nor do I need to, but I’m a bit worried that the conversion is going to be difficult. I don’t think it will help that I only work in the clinic for 4 hours a week, and I found that gave me a much longer learning curve for getting comfortable with e-prescribing, compared with the psychiatrists who work in clinic full-time.

Change is sometimes hard, and if I had a say, I’d rather it trickled in than came in a series of sequential storms. I’m whining. I know I’m whining, and as we lag our way out of a recession, I have had the fortune to be in a career I love, with no fears of unemployment. My days may include a few moments of swearing at computer screens and unwelcome adjustments to unwelcome changes, but the work I do with patients remains rewarding. Ah, indoor work with no heavy lifting, though certainly there are days where the responsibility weighs heavy. I’ll stop whining now, and perhaps 2014 can be the year of the psychiatrist, once we figure out the ACA, (also known as the Affordable Care Act, or Obamacare), that is.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

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