License/legal question

[Red Beard]

Soon to be 4th year student here.

I asked a similar question in another thread a while ago, but as I continue to obsess about the 'right' career path for me my question has evolved into the following:

If I were to pursue residency training in a non-psych specialty, say IM or FM, and also master's level training in psychotherapy resulting in licensing as a psychotherapist, is there any legal reason I could not have a private practice in which I treat patients for anxiety and depression employing both appropriate psychopharmacology and psychotherapy?

If anyone is curious as to why I would want to do this I'll elaborate in another post, but for now I'll just leave my question.

Thanks!

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[whopper]

From my understanding you can pretty much do any type of medicine despite what type of residency you do (now someone correct me if I'm wrong because that's what I heard & never looked up the legal books on this). I've heard this is allowable because in some underpopulated areas, there are only a few doctors who are thrust into sometimes having to handle something outside their usual spectrum of care. Before managed care took over, lots of non IM/ER/FM/GP doctors did primary care.

That advice is anectdotal. I'd really ask a lawyer or someone who knew for certain if you did such a non-conventional road.

However I can definitely say that if you do practice outside your conventional training, you are opening yourself up to non-evidenced practice risks, and risk of losing malpractice suits. Its not going to look good if for example you were sued for psychiatric malpractice, and you couldn't even say in court that you completed a psychiatric residency.

If you did go through FM, at least that path has some psychiatric training in it, so you may be able to hold your own in court with that path.

(Now someone go tell Dr. Laura to stop trying to make herself out to be a psychologist. Her degree may have been from Columbia but it was in Physiology.

 

[strangeglove]

You would be as qualified as any other FP or IM doctor to prescribe antidepressants (most of these prescriptions are actually written by primary care doctors as it is), but no more qualified. There are also questions about where you would learn how to deal with things like the acutely suicidal patient and the interaction of medical and psychiatric illnesses (i.e. psychosomatic medicine), which are standard parts of psychiatry training, but are not taught in most clinical psychology programs.

 

[IAmAUser]

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[Red Beard]

Wow, fast replies! Thanks! Some follow-up questions:

1) What I've seen is that much depression and anxiety is managed pharmacologically by a PCP without any consultation or input from a psychiatrist. I'm thinking of a small practice consisting of treating uncomplicated mild-moderate depression and anxiety in a select group of patients without significant medical comorbidities. Assuming that I would have the same ability to recognize an acutely suicidal patient as any other PCP or clinical psychologist, with the common sense that suicidal thinking-->psych ER, how would my risk be any greater than that assumed by an average FP or internist just because I also offer psychotherapy?

2) If a session consisted of 15 minutes medication management and 45 minutes psychotherapy, would I generally be allowed to bill for both?

 

[OldPsychDoc]

2) If a session consisted of 15 minutes medication management and 45 minutes psychotherapy, would I generally be allowed to bill for both?

You can BILL for anything you want. Whether you'll be paid is another issue.
A lot of 3rd party payors expect you to be board-certified, or at least board-eligible. (And I believe you'd only be allowed to bill for one type of session--so for example 90807(?) for 45 minute therapy session with E & M. )

For more than you want to know, but less than you need to know about Psych CPT codes--this is a nice document. Thanks AACAP!

 

[Regnvejr]

1) What I've seen is that much depression and anxiety is managed pharmacologically by a PCP without any consultation or input from a psychiatrist. I'm thinking of a small practice consisting of treating uncomplicated mild-moderate depression and anxiety in a select group of patients without significant medical comorbidities.

Family Pracitice does this all the time.

Assuming that I would have the same ability to recognize an acutely suicidal patient as any other PCP or clinical psychologist, with the common sense that suicidal thinking-->psych ER,

If you got one available.

how would my risk be any greater than that assumed by an average FP or internist just because I also offer psychotherapy?

because you offer specialized treatment in the area.

2) If a session consisted of 15 minutes medication management and 45 minutes psychotherapy, would I generally be allowed to bill for both?

There are codes specifically for that, such as therapy with E&M (medication management)

 

[Red Beard]

You can BILL for anything you want. Whether you'll be paid is another issue.
A lot of 3rd party payors expect you to be board-certified, or at least board-eligible. (And I believe you'd only be allowed to bill for one type of session--so for example 90807(?) for 45 minute therapy session with E & M. )

For more than you want to know, but less than you need to know about Psych CPT codes--this is a nice document. Thanks AACAP!

Thanks, that is a useful document, and appears to answer my question.

From the relevant section:

"If the therapist is a primary care provider (M.D., D.O., R.N., or P.A.), that person may add an E/M component to the therapy and bill the appropriate bundled code above. That provider must document the E/M service provided. Possible examples include:
Medical diagnostic evaluation including comorbid medical diagnoses
Drug management
Physician orders
Interpretation of laboratory or medical diagnostic tests
Physical examination. "

 

[Red Beard]

.....and based on that information, using their formula for medicare reimbursement, the scenario I describe would be billed as a 90813 at 3.01 RVUs and the reimbursement would be $114.64.

 

[michaelrack]

As stated, a license to practice medicine is generally unrestricted unless you have had some trouble with your state medical board. You could, for example, complete a psychiatry residency and then practice neurosurgery. The thing stopping people from doing this is that you are in a very poor position to be reimbursed by insurance companies, get malpractice insurance, or defend a malpractice claim if anything should go wrong.

Agree.

Would also add that you would need to disclose your background to your patients and not in any way imply that you had completed psychiatric residency.

 

[OldPsychDoc]

.....and based on that information, using their formula for medicare reimbursement, the scenario I describe would be billed as a 90813 at 3.01 RVUs and the reimbursement would be $114.64.

Only if you used an interpreter. Otherwise it's 90807, and you make a few dollars less. (You used the "interactive" code.)

Of course, if you'd seen 3 med management pts in that same hour, you'd have billed for 90862 * 3 = 3.77 RVUs!