A pile of my audited charts was arranged in front of the coding consultant. Next to her sat our billing specialist. It was 8:30 on a Thursday morning, in the middle of the half hour that I usually reserve to think, dictate letters, read about my difficult cases, and perform the myriad tasks that pile up by the end of the week. I understood that our group had actually requested this review. The mastery of evaluation and management codes was as much a requirement for medicine in the 1990s as board certification. I had mentally prepared myself (or so I had thought) to handle this critique of my billing practices.

What I didn't expect was the unbidden escalation of my annoyance as we began the scripted process. The coding consultant started with my raw data. Twelve of 22 charts were coded properly; just 55% correct. My scalp started to prickle. The consultant explained that the inconsistencies were errors of either upcoding or downcoding. Since I had always thought that upcoding (charging more than supported by documentation) was the egregious error, my chief concern was the two charts that apparently did not pass muster in this category.

The consultant leveled me with her look. "Any error in coding can potentially cause penalty," she said. "Those five cases that you undercoded are a red flag to HCFA. They signal that you don't know how to code, and that can prompt a full audit. And then payments can be reclaimed ... ." She droned on in her imperious tone. And I started to smolder.

I was angry that billing issues could even evoke in me that kind of emotion. With all of the ups and downs of training and clinical practice, I had gained a wider perspective and a cooler temperament than I had had in medical school days. Control of feelings was an element of my job. This sense of aggravation was, frankly, silly. But it was there! The spark ignited and I felt the fire flare.

"This doesn't take into account the time I spent explaining the issues to the patient, calling the family, calling the specialist, and making special arrangements, or the time spent thinking, feeling, caring ... ." The consultant stopped me halfway through my diatribe.

"What you do doesn't matter," she said patiently. "If you don't document it correctly, you don't get reimbursed and you could get fined."

There it was. Bureaucratic arrogance was the crux of my frustration. The dissection of the medical encounter had become so detailed that actual patient interaction was now secondary to fleshing out the chart for HCFA.

I wanted to say all this, but instead I kept silent. Emotional pyrotechnics would be wasted on them while consuming me. The coding consultant and the billing specialist were getting uncomfortable. They truly had no context for understanding.

By the time the meeting ended, I was 10 minutes late for my 9:00 patient. I found it difficult to concentrate during the consultation. The elements of coding hounded me. Did I get enough review of systems for a 99214? How about pertinent PFSH (past, family, and social history)? How complex was her problem, anyway? Was it moderately complex or highly complex? By whose standards?

Later that day, between appointments, I checked messages and mail. There was a letter addressed to me with PERSONAL stamped on the front. I opened it and found a notecard decorated with flowers and headlined "Thinking of You." It was carefully typed.

Dear Dr. Sumkin,

How are you? I hope you don't mind me writing you a note. It was very good to see you in the parking lot a week ago. I miss you sometimes. We have been through a lot together. You were always there for me. I know I can't waste your time and the state's money but sometimes I would just like to set and talk a bit. I could always tell you how I was feeling inside and out and you never put me down. You never made me feel like I was worthless or dumb. Thank you.

As the letter went on, the heat dissipated. I entered the next exam room ... a doctor.