Accurate to say Psychiatry faces most encroachment?

[nowaysanjose]

It seems like legislatures can be convinced that because Psych is the "least medical" of all specialties, that giving practice rights to psychologists to fill the gap does not pose a significant risk to patients. Couple the increasing number of states that are allowing prescribing psychologists with the rapid expansion of NP autonomy, is it fair to say that Psychiatry faces the most risk from encroachment, considering that other specialties do not have to worry about psychologists gaining practice rights, in addition to NPs gaining autonomy?

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[wolfvgang22]

Not necessarily. I see more encroachment by mid level providers in primary care than I do in psychiatry.

 

[SmallBird]

It seems like legislatures can be convinced that because Psych is the "least medical" of all specialties, that giving practice rights to psychologists to fill the gap does not pose a significant risk to patients. Couple the increasing number of states that are allowing prescribing psychologists with the rapid expansion of NP autonomy, is it fair to say that Psychiatry faces the most risk from encroachment, considering that other specialties do not have to worry about psychologists gaining practice rights, in addition to NPs gaining autonomy?

Encroachment is not the right term. Our territory is not being invaded; new and unoccupied territory is being settled by others in addition to ourselves. There may come a time when there are enough psychiatrists for all the jobs, and mid level competition lowers our pay. However at the moment the growing need continues to outpace rates of graduation. All of my colleagues remark on a recent tightening in supply of qualified practitioners and salary offers are higher this year.

 

[wolfvgang22]

More psychiatrists are retiring than are being trained. Two of the psychiatrists in my office will likely retire in the next 5+ years, which is half.

 

[nowaysanjose]

Encroachment is not the right term. Our territory is not being invaded; new and unoccupied territory is being settled by others in addition to ourselves. There may come a time when there are enough psychiatrists for all the jobs, and mid level competition lowers our pay. However at the moment the growing need continues to outpace rates of graduation. All of my colleagues remark on a recent tightening in supply of qualified practitioners and salary offers are higher this year.

I understand. I am thinking about psychiatry but am concerned with the idea that it is the only specialty that faces competition from two different sources.

 

[MacDonaldTriad]

The majority of psychotropics are not written by us. A few new players writing without much training isn't going to even be noticeable. Besides we do more than write scripts and only some of them do anything more than symptomatic protocol.

 

[PistolPete]

Not necessarily. I see more encroachment by mid level providers in primary care than I do in psychiatry.

Same.

 

[AnnoyedByFreud]

More psychiatrists are retiring than are being trained. Two of the psychiatrists in my office will likely retire in the next 5+ years, which is half.

I believe over 50% of psychiatrists are expected to retire in the next decade or so, from what I've read. It seems unlikely that the market will tighten up, given the fact that specializing in psych is very unpopular among NPs as well as MDs/DOs...

 

[PistolPete]

I believe over 50% of psychiatrists are expected to retire in the next decade or so, from what I've read. It seems unlikely that the market will tighten up, given the fact that specializing in psych is very unpopular among NPs as well as MDs/DOs...

Better for us! Shhh.... don't let out the secret!

 

[nowaysanjose]

Better for us! Shhh.... don't let out the secret!

I thought the general consensus was that competitiveness was increasing evidenced by the increasing number of US MDs entering the specialty--at ~70% up from 51% in 2012?

 

[F0nzie]

I believe over 50% of psychiatrists are expected to retire in the next decade or so, from what I've read. It seems unlikely that the market will tighten up, given the fact that specializing in psych is very unpopular among NPs as well as MDs/DOs...

I don't want to be left behind! Need to work on 10 year exit strategy stat.


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[SmallBird]

I thought the general consensus was that competitiveness was increasing evidenced by the increasing number of US MDs entering the specialty--at ~70% up from 51% in 2012?

I don't think that is a consensus. There are more medical schools, static residency slots, and a general decrease in IMGs across specialties, with psychiatry relatively stable in terms of relative competitiveness to other specialities.

 

[OldPsychDoc]

I understand. I am thinking about psychiatry but am concerned with the idea that it is the only specialty that faces competition from two different sources.

The "competition" from prescribing psychologists (which is frankly way overstated) is miniscule in volume compared to the amount of psychotropics prescribed by primary care. Don't choose your specialty based on where you think there's less competition. If you want to care for the mentally ill, then go to psychiatry. If you don't--then please go somewhere else.

 

[Blitz2006]

I thought the general consensus was that competitiveness was increasing evidenced by the increasing number of US MDs entering the specialty--at ~70% up from 51% in 2012?

This is partially correct, refer to table 8:

http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

Well, it went up to 61% in 2016 from 51% (2014), not 70%. But yes, in the past 2 years "competitiveness" has increased. Based on the preliminary ERAS numbers for 2017, I suspect/predict this year it will be around 65%, and therefore 3 consecutive years of substantial US MD increase. But its all relative, psych is still in the bottom 5 of specialties for competitiveness, its probably only more competitive than FM/Peds/PMR/IM. I think by 2020 Psych will be mid-tier in competitiveness, especially with $ and reimbursements going up noticebly in psych, as well as buyers job market. People will probably laugh and flame me for this statement, but the same thing happened back in 2013 when I applied and said that psych is due for an upswing, which did happen after 2015.

But competitiveness has nothing to do with job market, unless of course they suddenly double residency spots in the next 1-2 years. The shortage of psychiatrists is severe. You should be more concerned about matching into a strong psych program at this point, not encroachment.

 

[Merovinge]

The "competition" from prescribing psychologists (which is frankly way overstated) is miniscule in volume compared to the amount of psychotropics prescribed by primary care. Don't choose your specialty based on where you think there's less competition. If you want to care for the mentally ill, then go to psychiatry. If you don't--then please go somewhere else.

While this is 100% the money post, I will say that some people are scared after seeing what happened to Gas/Rads and think they might legitimately train for 4 years and not get a job. Mind you the gas/rads problems are heavily overstated in my opinion but if you listen to the wrong radiologist as a med student you might think the sky is falling.

To answer the OP, no one else in mental health gets the combination of extensive medical training and extensive treatment of the seriously mentally ill. Primary care already handles most of the "worried well" and the ones that come to psychiatry either have significant co morbidity (SUD, PD) or want to pay to have the top trained specialist, which is and will always be psychiatry.

 

[smalltownpsych]

The "competition" from prescribing psychologists (which is frankly way overstated) is miniscule in volume compared to the amount of psychotropics prescribed by primary care. Don't choose your specialty based on where you think there's less competition. If you want to care for the mentally ill, then go to psychiatry. If you don't--then please go somewhere else.

Even if every state eventually allowed psychologists to prescribe, not all would. I think that even in the states where psychologists have been prescribing for a number of years there is still a sizable majority who don't. Maybe in 50 years it will be a lot different, but I wouldn't worry about it now. When I started my doctoral program, it was the same time that New Mexico passed their law allowing some psychologists with extra training and supervised experience to prescribe. I thought that maybe by the time I was licensed that might become the norm and change the field. It has been 15 years since then and I don't think anything has really changed much.

 

[MacDonaldTriad]

I thought that maybe by the time I was licensed that might become the norm and change the field. It has been 15 years since then and I don't think anything has really changed much.

I wonder how much of this is because of the APA lobbying efforts, or just a lack of vacuum to pull psychologists in this direction. I have never met a psychologist who was interested in learning how to write scripts, but I’m not really out in the “for profit” world much.

 

[deleted343839]

I wonder how much of this is because of the APA lobbying efforts, or just a lack of vacuum to pull psychologists in this direction. I have never met a psychologist who was interested in learning how to write scripts, but I’m not really out in the “for profit” world much.

I agree. I think the "divide" on this issue within psychology is overstated. Some surveys show that about half of psychologists have a permissive attitude toward RxP legislation, but when you drill down to who actually intends to pursue the additional training and RxP credential you're in the single digits. Despite APA's (American Psychological Association) lobbying, the larger and more powerful sections/subspecialties within APA actually tend not to favor prescribing privileges or are at least silent on the issue. So there are some loud voices within psychology that get, at best, politely ignored rather than amplified by the rank-and-file. I actually resigned from my state psychological association in protest when the incoming president made noise about putting RxP high on the legislative agenda.

Anyway, it's not to say that competition between prescribing psychologists and psychiatrists could never happen, but it seems like a low-frequency sort of problem, certainly not of the magnitude that should sway someone's decision to enter the profession.

 

[MacDonaldTriad]

Ironic, I resigned from our APA when they made blocking psychologists from prescribing their major effort. We have so many other important issues to spend money on.

 

[nowaysanjose]

While this is 100% the money post, I will say that some people are scared after seeing what happened to Gas/Rads and think they might legitimately train for 4 years and not get a job. Mind you the gas/rads problems are heavily overstated in my opinion but if you listen to the wrong radiologist as a med student you might think the sky is falling.

To answer the OP, no one else in mental health gets the combination of extensive medical training and extensive treatment of the seriously mentally ill. Primary care already handles most of the "worried well" and the ones that come to psychiatry either have significant co morbidity (SUD, PD) or want to pay to have the top trained specialist, which is and will always be psychiatry.

Hey thanks, because yes as a med student we don't really know anything and we're just repeating what we're hearing, and what we're hearing is doom and gloom. One doctor I talked to said, yeah, prescribing psychologists aren't a threat right now, but it's only 3 states--what happens if/when it's 50 states? People said NPs would expand either, now they're pushing 30 states. And who is to say that the requirement to prescribe maintains doctorate level? If they let people with master's degrees practice medicine, why wouldn't they let people with a master's degree prescribe for psych? Basically they said never underestimate the ignorance of lawmakers when it comes to these things.

 

[nowaysanjose]

This is partially correct, refer to table 8:

http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

Well, it went up to 61% in 2016 from 51% (2014), not 70%. But yes, in the past 2 years "competitiveness" has increased. Based on the preliminary ERAS numbers for 2017, I suspect/predict this year it will be around 65%, and therefore 3 consecutive years of substantial US MD increase. But its all relative, psych is still in the bottom 5 of specialties for competitiveness, its probably only more competitive than FM/Peds/PMR/IM. I think by 2020 Psych will be mid-tier in competitiveness, especially with $ and reimbursements going up noticebly in psych, as well as buyers job market. People will probably laugh and flame me for this statement, but the same thing happened back in 2013 when I applied and said that psych is due for an upswing, which did happen after 2015.

But competitiveness has nothing to do with job market, unless of course they suddenly double residency spots in the next 1-2 years. The shortage of psychiatrists is severe. You should be more concerned about matching into a strong psych program at this point, not encroachment.

I think I was looking at charting outcomes and it said 69%

 

[thoffen]

Demand significantly exceeds supply. My understanding is that, regardless of midlevels/psychologists/pcps doing psychiatric care, demand is outgrowing supply. Psychiatrists are better than safe at the moment.

 

[FlowRate]

I think the demand for psychiatrists (gross demand -- all mentally ill / people with multiple social difficulties) will always exceed supply. Psychiatrists respond to the same incentives as everyone else. That is, a lot of people want to make the most money in the easiest way possible. You don't do that in a CMHC.

 

[Shikima]

I think the demand for psychiatrists (gross demand -- all mentally ill / people with multiple social difficulties) will always exceed supply. Psychiatrists respond to the same incentives as everyone else. That is, a lot of people want to make the most money in the easiest way possible. You don't do that in a CMHC.

Money, dumping work, red-headed step child of medicine, lack of parity despite laws, poor support from systems, etc

Mr. So-and-so is really (difficult) ... Oh, just consult psychiatry.

 

[postbacpremed87]

I was reading something that said half of psychiatrists are 60+. It is the oldest medical specialty. Given the population boom, recent emphasis on mental health, and the shortage, I think the market for the next 20-30 years will be excellent. Sure PsyD may get Rx rights but who is going to take care of the psychotic patient with acute on chronic renal failure? ....not NPs or PsyDs

 

[AcronymAllergy]

I agree. I think the "divide" on this issue within psychology is overstated. Some surveys show that about half of psychologists have a permissive attitude toward RxP legislation, but when you drill down to who actually intends to pursue the additional training and RxP credential you're in the single digits. Despite APA's (American Psychological Association) lobbying, the larger and more powerful sections/subspecialties within APA actually tend not to favor prescribing privileges or are at least silent on the issue. So there are some loud voices within psychology that get, at best, politely ignored rather than amplified by the rank-and-file. I actually resigned from my state psychological association in protest when the incoming president made noise about putting RxP high on the legislative agenda.

Anyway, it's not to say that competition between prescribing psychologists and psychiatrists could never happen, but it seems like a low-frequency sort of problem, certainly not of the magnitude that should sway someone's decision to enter the profession.

Agreed. Even in the 3 states that currently allow RxP, there are access issues and shortages of providers. I'd imagine that if 100% of psychologists suddenly started prescribing (which will not be happening in anyone here's lifetime), there would still be a shortage in many, if not most, areas.

 

[Merovinge]

I was reading something that said half of psychiatrists are 60+. It is the oldest medical specialty. Given the population boom, recent emphasis on mental health, and the shortage, I think the market for the next 20-30 years will be excellent. Sure PsyD may get Rx rights but who is going to take care of the psychotic patient with acute on chronic renal failure? ....not NPs or PsyDs

You can even forgo the renal failure. Real management of psychosis is minimally taught to most PhD/PsyDs. Ive seen psychologists (who are otherwise extremely intelligent and great at what they do) not even understand what psychosis is, much less how to manage it.

 

[Jules A]

I was reading something that said half of psychiatrists are 60+. It is the oldest medical specialty.

Yeah and I personally would like to see some of them finally tap out. Without a doubt even in their current pre-dementia state they have forgotten more knowledge than I will ever have but for the love of Pete the nonsensical polypharm especially for our drug seeking SUD population is wearing me out.

 

[deleted343839]

Real management of psychosis is minimally taught to most PhD/PsyDs. Ive seen psychologists (who are otherwise extremely intelligent and great at what they do) not even understand what psychosis is, much less how to manage it.

That would be me, frankly, and that is why I leave psychiatry to the pros.

 

[PsyDr]

I wonder how much of this is because of the APA lobbying efforts, or just a lack of vacuum to pull psychologists in this direction. I have never met a psychologist who was interested in learning how to write scripts, but I’m not really out in the “for profit” world much.

I am licensed as a prescribing/medical psychologist and have never practiced as such because there's no benefit for me. IMO, it's stupid to be concerned about this. I do believe that if psychiatry was really concerned about this, practitioners should hire medical/prescribing psychologists as another source of midlevels for both safety and profit

Practice: In RxP states, psychologists can only prescribe after a physician has approved the script. Yeah, not even close to the same level of independence of NPs and PAs, state depending. What's the significant difference from this practice and that of other states? I can see a patient and recommend a medication in pretty much any state in the nation. Physicians can call me an idiot and say no in any state in the nation. So what's the benefit?

Money: IMO, money is not substantially better unless we are talking about cash based practice. With insurance, say your practice is mostly comprised of 99213. So around $200-300/hr if your productivity is 100%. In neuropsych, I can make at least that using technicians without being face to face with patients if I wanted. There are other cash based practice areas which are as or more lucrative than prescribing (e.g., psychoanalysis, forensics, etc).

Demand: Demand is much higher for prescribing/medical psychologists. While this may drive the increased money for psychologists, it means more work. IME, most of the demand comes from patients with crappy insurance. I don't know about anyone else, but I'd prefer to do high pay/low volume work rather than the converse. My analyst's 50 minute "hour" is higher in cost than four E/M codes.

Hassle: Frankly, prescribing looks like a hassle. If I see someone for a neuropsych assessment, no one is calling me at odd hours because they have had an adverse reaction to crap, or "lost" their scheduled stuff, or whatever. No one is calling me from a pharmacy about insurance stuff. If I do forensics, there's no surprise person in my waiting room or need for coverage when I want to go on vacation or get drunk.

 

[Therapist4Chnge]

You can even forgo the renal failure. Real management of psychosis is minimally taught to most PhD/PsyDs. Ive seen psychologists (who are otherwise extremely intelligent and great at what they do) not even understand what psychosis is, much less how to manage it.[/b[

Huh?

That is quite a…..reach. Can you please cite some programs to back up your statement, as your experience does not align with the curriculums mandated in accredited programs. Psychologists obviously practice in many different settings, though many of them provide services for actively psychotic patients and some conduct research led by psychologists on the topic and related areas.

 

[AnnoyedByFreud]

Yeah and I personally would like to see some of them finally tap out. Without a doubt even in their current pre-dementia state they have forgotten more knowledge than I will ever have but for the love of Pete the nonsensical polypharm especially for our drug seeking SUD population is wearing me out.

I have inherited some patients on some ... incredible regimens. I had an 80 yo patient who was hospitalized and the IOP psychiatrist put him on Adderall, Ambien, and Ativan. Somehow the psychiatrist didn't realize that the true cause of this pt's erratic energy and sleeping issues was his untreated sleep apnea. Apparently after completing IOP and on the above regimen (before he got in to see me) the patient became confused at home, took too much Ambien, and got in a car accident. Sigh.

 

[Therapist4Chnge]

My experience mirrors PSYDR's. I am not yet licensed as a prescribing psychologist, though I completed the training awhile back as a way to inform my research. Certain types of assessment are far better options for most psychologists because we have far less off-hour issues and it is very time limited (typically only see the patient 1-2 times to complete an assessment).

The bigger threat to psychiatry continues to be managed care organizations. They are dictating (restricting) practice and adding additional red tape to everything in healthcare. I guess some might argue that mid-levels are a threat, but given the supply/demand imbalance, I think that is a harder argument. There are so few psychologists who go through the extra years of training to prescribe, I highly doubt it will put a major dent in the imbalance, though for every psychologist that does do it, they can chip away at the imbalance.

 

[Merovinge]

Huh?

That is quite a…..reach. Can you please cite some programs to back up your statement, as your experience does not align with the curriculums mandated in accredited programs. Psychologists obviously practice in many different settings, though many of them provide services for actively psychotic patients and some conduct research led by psychologists on the topic and related areas.

Many of them provide services for actively psychotic patients? I'm not sure how you define many, but that sounds like a ... reach. Certainly some of the big researchers in psychosis are psychologists and some do CBTp, it's absolutely an area that falls under the domain of psychology that can be specialized in. That said, Id like to see what programs you are referring to where the management of active psychosis is done by psychologists. Literally every psychiatrist has several hundred if not thousands of hours working in this area staffing emergency rooms and doing admissions to inpatient units along with taking call. Many of the psychology trainees at my very program have either no or next to no clinical exposure to psychosis and these are very competitive spots with students from across the country.

I certainly don't mean to say that psychosis cant be treated by psychologists, but they absolutely get way less clinical training in the area. Id actually love it if there was more CBTp practitioners but whats paying the bills for most psychologists is not psychosis. There is so much false equivalence these days that I think its very important prospective students be clear about the differences in training between fields.

 

[SansaStarkMD]

Psychiatry cannot be encroached upon. It is all subjective opinions therefore whoever has the highest qualifications on paper gets the final say.

 

[smalltownpsych]

Many of them provide services for actively psychotic patients? I'm not sure how you define many, but that sounds like a ... reach. Certainly some of the big researchers in psychosis are psychologists and some do CBTp, it's absolutely an area that falls under the domain of psychology that can be specialized in. That said, Id like to see what programs you are referring to where the management of active psychosis is done by psychologists. Literally every psychiatrist has several hundred if not thousands of hours working in this area staffing emergency rooms and doing admissions to inpatient units along with taking call. Many of the psychology trainees at my very program have either no or next to no clinical exposure to psychosis and these are very competitive spots with students from across the country.

I certainly don't mean to say that psychosis cant be treated by psychologists, but they absolutely get way less clinical training in the area. Id actually love it if there was more CBTp practitioners but whats paying the bills for most psychologists is not psychosis. There is so much false equivalence these days that I think its very important prospective students be clear about the differences in training between fields.

I think you are right in saying that many psychologists do not have much experience working with psychotic individuals, but it really depends on where they got their training. I sought out settings where I would get more exposure to serious mental illness; whereas many do not. That isn't likely an option for psychiatrists. Don't know the actual numbers on any of this so it is difficult to say anything more definitively than that.

On a philospohical tangent, I actually do think that psychologists should be more involved in the treatment of patients with psychotic disorders. Unfortunately, I have seen the midlevel counselors with even more limited understanding or experience being the ones working with these patients. In some settings psychologists are very much involved and often taking the lead in treatment, some of the state hospitals and VA hospitals being places where I have seen this, on the other hand, at many CMHs there is nary a psychologist to be seen.

 

[sweetlenovo88]

I am licensed as a prescribing/medical psychologist and have never practiced as such because there's no benefit for me. IMO, it's stupid to be concerned about this. I do believe that if psychiatry was really concerned about this, practitioners should hire medical/prescribing psychologists as another source of midlevels for both safety and profit

Practice: In RxP states, psychologists can only prescribe after a physician has approved the script. Yeah, not even close to the same level of independence of NPs and PAs, state depending. What's the significant difference from this practice and that of other states? I can see a patient and recommend a medication in pretty much any state in the nation. Physicians can call me an idiot and say no in any state in the nation. So what's the benefit?

Money: IMO, money is not substantially better unless we are talking about cash based practice. With insurance, say your practice is mostly comprised of 99213. So around $200-300/hr if your productivity is 100%. In neuropsych, I can make at least that using technicians without being face to face with patients if I wanted. There are other cash based practice areas which are as or more lucrative than prescribing (e.g., psychoanalysis, forensics, etc).

Demand: Demand is much higher for prescribing/medical psychologists. While this may drive the increased money for psychologists, it means more work. IME, most of the demand comes from patients with crappy insurance. I don't know about anyone else, but I'd prefer to do high pay/low volume work rather than the converse. My analyst's 50 minute "hour" is higher in cost than four E/M codes.

Hassle: Frankly, prescribing looks like a hassle. If I see someone for a neuropsych assessment, no one is calling me at odd hours because they have had an adverse reaction to crap, or "lost" their scheduled stuff, or whatever. No one is calling me from a pharmacy about insurance stuff. If I do forensics, there's no surprise person in my waiting room or need for coverage when I want to go on vacation or get drunk.

Interesting, so what kind of money are business oriented psychologists making on an annual basis? Do you get burn out after a certain amount of psychoanalysis per day? How does reimbursement work for neuropsychiatry? Feel free to PM the answers if you prefer

 

[PsyDr]

Interesting, so what kind of money are business oriented psychologists making on an annual basis? Do you get burn out after a certain amount of psychoanalysis per day? How does reimbursement work for neuropsychiatry? Feel free to PM the answers if you prefer

I'd be happy to PM you. I am an outlier, and try to avoid disclosing income because I fear students will assume this is a certainty.

I do not perform psychoanalysis, but an in analysis which is the basis of my experience. My first analyst was a "name" and charged around $350-400/hr, minimum of 3x/wk. My current analyst's charges are consistent with approximately four 99213s. I don't know how burnt out they get. I'd fall asleep if I had to listen to me for an hour.

Neuropsychology bills just like every other cpt out there. But we can use our version of extenders, which multiplies income.

 

[DJspreadsheet]

I'd be happy to PM you. I am an outlier, and try to avoid disclosing income because I fear students will assume this is a certainty.

I do not perform psychoanalysis, but an in analysis which is the basis of my experience. My first analyst was a "name" and charged around $350-400/hr, minimum of 3x/wk. My current analyst's charges are consistent with approximately four 99213s. I don't know how burnt out they get. I'd fall asleep if I had to listen to me for an hour.

Neuropsychology bills just like every other cpt out there. But we can use our version of extenders, which multiplies income.

I should point out that most standard outpt psych visits are coded at 99214, and you can easily see 3/hr (responsibly), which translates into significant increase in reimbursement. Won't argue that analysis isn't the golden goose in max potential however. For those that can stomach it. I'd rather mown lawns. Literally.

 

[PsyDr]

I should point out that most standard outpt psych visits are coded at 99214, and you can easily see 3/hr (responsibly), which translates into significant increase in reimbursement. Won't argue that analysis isn't the golden goose in max potential however. For those that can stomach it. I'd rather mown lawns. Literally.

When I completed some continuing education to learn billing, the instructors indicated that e/ms should follow a normal curve with 99213s being the majority. They stated that not following this curve is a method insurers use to identify clinics needing an audit. Medscape puts 99213s (in medicine in general, not psych specific) as about ~40% of claims. Might want to be careful.

 

[nexus73]

When I completed some continuing education to learn billing, the instructors indicated that e/ms should follow a normal curve with 99213s being the majority. They stated that not following this curve is a method insurers use to identify clinics needing an audit. Medscape puts 99213s (in medicine in general, not psych specific) as about ~40% of claims. Might want to be careful.

This sounds close to reality, but the 40% number doesn't make sense
If 99213 is 40% of the claims, that leaves 60% for 99214 and 99215...because outpatient every visit is at least 99213, nobody bills 99211 or 99212 (just because even the lowest complexity visit is a 99213). So what, are people billing 30% 99214 and 30% 99215? I would guess it's more like 30% 99213, 60% 99214, and 10% 99215 (or less). And this all depends on the severity of patients you are seeing, too. If it's all adult ADHD followup or mild MDD, everybody is probably a 99213. If it's community mental health with multiple dx and addiction, every visit would almost have to be 99214 at least.

And if you're billing for a 30 minute appointment, 2 per hour, every one is at least a 99214 as well.

 

[Shikima]

This sounds close to reality, but the 40% number doesn't make sense
If 99213 is 40% of the claims, that leaves 60% for 99214 and 99215...because outpatient every visit is at least 99213, nobody bills 99211 or 99212 (just because even the lowest complexity visit is a 99213). So what, are people billing 30% 99214 and 30% 99215? I would guess it's more like 30% 99213, 60% 99214, and 10% 99215 (or less). And this all depends on the severity of patients you are seeing, too. If it's all adult ADHD followup or mild MDD, everybody is probably a 99213. If it's community mental health with multiple dx and addiction, every visit would almost have to be 99214 at least.

And if you're billing for a 30 minute appointment, 2 per hour, every one is at least a 99214 as well.

I wish I knew the documentation difference for a 914 v 915

 

[splik]

I wish I knew the documentation difference for a 914 v 915

its a pain if doing it by elements. if you do it on time, its 40mins vs 25mins. Otherwise it's a pain and I never use it. You have to have vitals, a full MSE, full systems review, complete PMFSH and they have to be of significant complexity to require it. the most common scenarios for psychiatry would be: 1) suicidal ideation and need hospitalization 2) homicidal ideation and need hospitalization 3) serotonin syndrome and need hospitalization 4) NMS and need hospitalization. also 99215s are audited by insurance companies most frequently for "medical necessity"

BTW, the APA says 99213 is/should be the most common code used for outpatient psychiatry. 99214 should be used for very complex cases. 99212 should be used for straightforward med refills in stable patients. I don't know anyone who uses 99212 however. using 99214 most commonly probably means upcoding. even if you see pts for 30mins, it is likely 99213+90833 is more appropriate than 99214 (and it pays more to use the add on codes so makes more financial sense as well as being more ethical).

 

[DJspreadsheet]

.

 

[PistolPete]

When I completed some continuing education to learn billing, the instructors indicated that e/ms should follow a normal curve with 99213s being the majority. They stated that not following this curve is a method insurers use to identify clinics needing an audit. Medscape puts 99213s (in medicine in general, not psych specific) as about ~40% of claims. Might want to be careful.

What if I code a 99213+90833 for almost every 30 minute visit, since I believe almost every patient will have symptoms that should be treated with therapy? Will I get audited?

 

[Shikima]

its a pain if doing it by elements. if you do it on time, its 40mins vs 25mins. Otherwise it's a pain and I never use it. You have to have vitals, a full MSE, full systems review, complete PMFSH and they have to be of significant complexity to require it. the most common scenarios for psychiatry would be: 1) suicidal ideation and need hospitalization 2) homicidal ideation and need hospitalization 3) serotonin syndrome and need hospitalization 4) NMS and need hospitalization. also 99215s are audited by insurance companies most frequently for "medical necessity"

BTW, the APA says 99213 is/should be the most common code used for outpatient psychiatry. 99214 should be used for very complex cases. 99212 should be used for straightforward med refills in stable patients. I don't know anyone who uses 99212 however. using 99214 most commonly probably means upcoding. even if you see pts for 30mins, it is likely 99213+90833 is more appropriate than 99214 (and it pays more to use the add on codes so makes more financial sense as well as being more ethical).

This makes sense to me. If you're hospitalizing or increasing the level of care for them (IOP/PHP), then bill at a 99215.

 

[PsyDr]

What if I code a 99213+90833 for almost every 30 minute visit, since I believe almost every patient will have symptoms that should be treated with therapy? Will I get audited?

I'm not really the one to ask. I don't bill E/M codes. Medacape has a graph and most cme/ce courses I took had graphs.

 

[Merovinge]

This makes sense to me. If you're hospitalizing or increasing the level of care for them (IOP/PHP), then bill at a 99215.

And even then it will always be because it takes 40 min of time including counseling and coordination of care rather than hitting the elements. Good luck documenting a level 5 while putting out the fire that requires that hospitalization.

 

[Shikima]

And even then it will always be because it takes 40 min of time including counseling and coordination of care rather than hitting the elements. Good luck documenting a level 5 while putting out the fire that requires that hospitalization.

I document afterwards for the full billing amount on a 215.

 

[Gavanshir]

I'm a PGY-1 psych resident and recently started my CPEP rotation. When the hell did social workers become equivalent to residents? Do all CPEPs employ social workers as clinicians? Is this standard practice? Where else do social workers take on the exact same role as an MD?