I've a patient who brings a dog to therapy. The little critter is adorable, and he sits there attentively and listens to every interpretation I make. Do I bill Blue Cross for conjoint or individual psychotherapy?
Several folks I see complain of lovelessness. It is very acute and causes immense despair, but the entity is not in our catalog of illnesses. How do I denote the condition on the invoice?
Thumbing through our bible, the Diagnostic and Statistical Manual, I see the range of man's desperations: anxiety disorders, depression, sexual dysfunction, the schizophrenias, a whole list of dismays. Each one is coded and numbered and most subjects correspond to the hallowed International Classification of Diseases, though this country is a bit ahead in this taxonomy, largely due to the medical profession's fevered need to appease the insurance companies. American diagnostics, I am convinced, have less to do with the reality of disease and much more to do with the suffering of third-party payers. It hurts them terribly to reimburse.
Someday soon, most of us in the office will talk codes, like secret agents. ''I saw an interesting 309.28 [adjustment disorder],'' my colleague will whisper to me. Or ''Be very careful. He's got a terrible case of 300.40 [dysthymia].
''Treat him with 90844,'' I'll crisply direct, referring to individual medical psychotherapy as if I were in the operating room stanching the gush of blood from a ruptured aorta. ''Adjunctive 90847 might also be in order. ''Nurse!'' I'll call out sharply, ''Schedule this man for a 90847 [family therapy]. Stat!''
''He could really benefit from 90862 [chemotherapy],'' someone
will challenge me. Now this suggestion conjures up a whole different ball game with sore spots and rivalries. Chemotherapy management, the euphemism for drugs, is something only we physicians can do so we cherish the procedure deeply and it is one of the remaining bastions of doctorhood. We divide our world in MDs and Non-MDs, as though the latter were from the science fiction Planet of the Living Dead. The Non-MDs talk, and we MDs medicate. Of course MDs talk, too, but our talking is, well, more medical. We describe dissociated states, organic brain syndromes, psychotic decompensation.
What ''they'' talk about is vague stuff like happiness and contentment, irrelevancies that surely don't require Hippocratic ordination. Except, despite oaths to the contrary, I find myself trying to help with issues of identity and creativity. Am I a non-physician, then? Or just a social commentator? Perhaps we need to create a new bill for Quality of Life Therapy, 95301, 30 minutes.
The other day I went to see a doctor. I waited a while, and my name was finally called. When I arose, I was led not into the doctor's office but into the billing office. It was a lovely room, far more decorative and spacious than the doctor's consulting room. Women sat behind computer screens and mumbled numbers and there was a reverent hush about the place. Forms were quietly pressed into my hand. My insurance card was scrutinized and I was queried at length about my financial existence. The rigor of this examination far exceeded that rendered by the doctor, but the drugs he gave me worked, so who am I to complain?
On the way out, I wondered whether I had participated in a brief office visit (BOV) or an intermediate office visit (IOV). One can never be sure about these things, of course, since the difference is only one digit in the code.
Dr. Lion practices psychiatry in Baltimore.