race to the bottom job offer....

[digitlnoize]

You don't have to do it on EVERY case. The point was that with the new coding and rates, Med+therapy time is approximately equal to med+med time. So, it no longer hurts the bottom line much to do therapy. A full day of 15 min med checks would be more profitable anyways.
You can go here and do your own math: http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

For my area, seeing this sequence:

1/2 hour med + therapy
1/4 hour med 99213
1/4 hour med 99213
1/2 hour med 99214
1/4 hour med 99213
1/4 hour med 99213

From 8-5 with a 1 hour break for lunch, will pay ~$2000/day, give or take. All Medicare. For private add more to that.

Note: I also feel this is likely under billing 99214's. A 1:4 ration of 4's to 3's is likely to low. You should be able to get them closer to 1:1, or even 1.5-2:1. And yes, this is an ESTIMATE. Many factors are missing, including private insurance (+15-25%), cash? (+50-100%), higher or lower overhead, other provider employees (midlevels? psychiatrists? therapists?), market area costs (NYC vs Nebraska), and about a billion other things I can't account for outside of an MBA class.

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[michaelrack]

What then is the standard for determining the medical necessity for psychotherapy?

http://www.law.uh.edu/healthlaw/perspectives/Managed/001129Difficulties.html Good question without a clear answer. I guess the standard is whatever the government auditor says it is.

 

[TexasPhysician]

You have to go further though and ask- is the therapy *I'm* offering in this setting(which would likely be 15-20 minutes of supportive therapy every 8 weeks or whatever) the right treatment? Some patients aren't going to benefit from therapy at all. Many will, but need much more intensive or focused therapy. Many will need much more frequent therapy than e/m coding would allow. Those are three of the biggest issues with scheduling 16 pts a day in 30 minute slots and expecting to E/M + add on every on. There is no way that most of those patients are going to require a care plan that jives with that model. It's purely for the sake of the business model of the psychiatrist.

Other than active mania/psychosis/delirium/dementia, I feel like most could benefit from therapy.

I'm probably more liberal in believing those without any dsm5 diagnosis could still benefit from therapy.

 

[Shikima]

Other than active mania/psychosis/delirium/dementia, I feel like most could benefit from therapy.

I'm probably more liberal in believing those without any dsm5 diagnosis could still benefit from therapy.

I've always had the notion, anyone who is receiving medications would also benefit from psychotherapy.

 

[billypilgrim37]

MI does not count as psychotherapy. It can be used as counseling and coordination of care. Not because MI isn't important, but I've read/been told by an APA representative that it is specifically not therapy for billing purposes.

I only use the add-on's when I am specifically using systematic therapy techniques. I was well-trained in family therapy, and when I find myself using those specific techniques in an appointment that likely explodes and last 45 minutes anyway, yes I bill for the therapy add-on. When I am specifically using CBT techniques and systematic problem-solving for a sustained period in a visit, then I bill for the add-on. Even supportive psychotherapy is a specific set of techniques that are not just just getting a psychosocial update. I do think you can do some limited quality psychotherapy on an intermittent basis. If someone is in regular therapy, using some of the same techniques with the patient is a reinforcement of the primary therapy (when they're in CBT), and is totally reasonable. Most of my visits are time based at 25-30 minutes and billed at 99214's. Anyone could look at my schedule and see that it could be legitimate. Most of that is psychoeducation and counseling or sending emails to their other providers WHILE THEY'RE IN THE ROOM WITH ME to make sure that I am saying what they want me to say. No more than maybe 1 in 8 or 1 in 10 would I call real psychotherapy.

 

[Addiction]

MI does not count as psychotherapy. It can be used as counseling and coordination of care. Not because MI isn't important, but I've read/been told by an APA representative that it is specifically not therapy for billing purposes.

I only use the add-on's when I am specifically using systematic therapy techniques. I was well-trained in family therapy, and when I find myself using those specific techniques in an appointment that likely explodes and last 45 minutes anyway, yes I bill for the therapy add-on. When I am specifically using CBT techniques and systematic problem-solving for a sustained period in a visit, then I bill for the add-on. Even supportive psychotherapy is a specific set of techniques that are not just just getting a psychosocial update. I do think you can do some limited quality psychotherapy on an intermittent basis. If someone is in regular therapy, using some of the same techniques with the patient is a reinforcement of the primary therapy (when they're in CBT), and is totally reasonable. Most of my visits are time based at 25-30 minutes and billed at 99214's. Anyone could look at my schedule and see that it could be legitimate. Most of that is psychoeducation and counseling or sending emails to their other providers WHILE THEY'RE IN THE ROOM WITH ME to make sure that I am saying what they want me to say. No more than maybe 1 in 8 or 1 in 10 would I call real psychotherapy.

MI is the only evidence-based therapy for substance use disorders. I think you can justify a psychiatrist getting compensated for MI with substance use patients along with medical managment of their substance use disorders rather than the insurance company also paying a substance use counselor for separate counseling sessions.

 

[Shikima]

With the amount of BZD being prescribed .... you could justify MI being used. :/

 

[billypilgrim37]

MI is the only evidence-based therapy for substance use disorders. I think you can justify a psychiatrist getting compensated for MI with substance use patients along with medical managment of their substance use disorders rather than the insurance company also paying a substance use counselor for separate counseling sessions.

Well, MI certainly isn't the only evidence-based therapy for substance use disorders. You certainly can get compensated for MI, as counseling and coordination of care time. Just not as a psychotherapy add-on. Pretty much your entire approach to patients should be MI-based anyway, so it's not a separate set of therapeutic techniques set off from an E&M visit.

Note, you can probably GET AWAY with calling MI "supportive psychotherapy" and do it as an add-on. But technically speaking it is just part of the counseling portion of a visit, which is not psychotherapy. A PCP should be doing the same intervention around diet and exercise (not that they do often), and you wouldn't expect them to be paid extra for a psychotherapy add-on. Some PCPs are better trained in MI around here than some of the addiction therapists are.

 

[Addiction]

Well, MI certainly isn't the only evidence-based therapy for substance use disorders. You certainly can get compensated for MI, as counseling and coordination of care time. Just not as a psychotherapy add-on. Pretty much your entire approach to patients should be MI-based anyway, so it's not a separate set of therapeutic techniques set off from an E&M visit.

Note, you can probably GET AWAY with calling MI "supportive psychotherapy" and do it as an add-on. But technically speaking it is just part of the counseling portion of a visit, which is not psychotherapy. A PCP should be doing the same intervention around diet and exercise (not that they do often), and you wouldn't expect them to be paid extra for a psychotherapy add-on. Some PCPs are better trained in MI around here than some of the addiction therapists are.

Not sure what your exposure is to Motivational interviewing (done the right way) but there is a big difference between an Addiction Psychiatrist treating a patient with opioid addiction with buprenorphine & MI techniques vs. a PCP (or any type of physician) using buprenorphine only especially when the patient continues to struggle. MI is a form of therapy with techniques and structure similar to other therapy modalities. MI is not just counseling a patient on a better diet and lifestyle. But if it has to be billed as Supportive psychotherapy in order to qualify for the add on so be it.

 

[michaelrack]

I've always had the notion, anyone who is receiving medications would also benefit from psychotherapy.

I've always had the notion that anyone with sleep apnea would benefit from cpap (although other options, including positional therapy, may also be appropriate if the pt prefers)- however medicare and other insurers often don't cover cpap for mild osa, event though many cases of mild osa benefit from cpap.

A majority of my pts are prescribed cpap, and I do think it is legitmate if a psychiatrist performs psycotherapy for a majority of pts

 

[billypilgrim37]

Not sure what your exposure is to Motivational interviewing (done the right way) but there is a big difference between an Addiction Psychiatrist treating a patient with opioid addiction with buprenorphine & MI techniques vs. a PCP (or any type of physician) using buprenorphine only especially when the patient continues to struggle. MI is a form of therapy with techniques and structure similar to other therapy modalities. MI is not just counseling a patient on a better diet and lifestyle. But if it has to be billed as Supportive psychotherapy in order to qualify for the add on so be it.

None of that has anything to do with it being a "therapy." I do MI trainings at National Meetings. I trained under Ken Resnicow who wrote several chapters in the M&R book. Even the book says that MI is not a therapy so much as a "way of being" with a patient. I do MI everyday with pot smoking adolescents and self-injuring teenage girls. Many of the PCPs in our IM dept have received extensive training in MI, probably better than many psychiatry residencies. It's a specific intervention, but one that resolves ambivalences to allow someone to engage in treatment. It's a form of counseling in the eyes of the coders. That doesn't make it somehow less valuable or less vital an intervention.

 

[Doctor Bagel]

I absolutely admit that I could not bear to read this entire thread so I may be off, but about 100 posts in it looked like Vistaril was saying he found a job he felt okay about in an area that is somewhat limited geographically. Just speculation, but maybe his GI gal got a great offer around there and so he's a bit limited geographically? He prioritized not having to see patients too quickly (as he said, ethical), and he's working under 40 hours a week. Yes the lack of benefits is disappointing and this isn't a super sweet deal, but I got the sense that he was really happy with it and was prioritizing patient care and lifestyle over income.

What am I missing? (granted, I skipped large blocks because it seemed like it was getting crazy)

Congrats, V. It sounds like you feel good with this, and that's awesome.

Yes, this. Congratulations, Vistaril, on a job you're OK about.

 

[heyjack70]

None of that has anything to do with it being a "therapy." I do MI trainings at National Meetings. I trained under Ken Resnicow who wrote several chapters in the M&R book. Even the book says that MI is not a therapy so much as a "way of being" with a patient. I do MI everyday with pot smoking adolescents and self-injuring teenage girls. Many of the PCPs in our IM dept have received extensive training in MI, probably better than many psychiatry residencies. It's a specific intervention, but one that resolves ambivalences to allow someone to engage in treatment. It's a form of counseling in the eyes of the coders. That doesn't make it somehow less valuable or less vital an intervention.

I think it should count as therapy.