pain psychologist

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
D

drpainfree

Full Member
15+ Year Member
Joined
May 3, 2009
Messages
1,178
Reaction score
225
just spent an hour with a young, female patient who was catastrophizing her cervical radiculopathy symptoms. my staff hated me because I kept them in the office at 6:30pm on Saturday afternoon.

while I feel pain psychology is an integral part of pain management, I'm not sure I'm doing the best job a patient deserves. I have sent patients out for psych therapy with psychologists who do my SCS psych clearance. my patients would always end up unhappy with their services.

Here's the question, any of you offers psych therapy in your office for pain management? We had them on staff in fellowship, but I have seen few private practices hiring pain psych on staff.

Is it really profitable to hire a psychologist or even psych therapist to come in once a week and talk to these patients about their insight, expectation, and coping skills, even co-manage their depression, anxiety, etc?

How do you bill for these services?

Thanks for the input.
Members don't see this ad.
 
Send to CSW. Less costly. Less mental health stigma for insurance or patient.

Shout out to Centerpoint Counseling in Woodstock Georgia.

it’s about time YOU got into counseling
 
i send out to pain psych all the time. like literally, more referrals to psych than to even PT or rads.

most go to a counsellor, as Medicaid does not cover psychological treatment. of course, these are generally the patients that require actual psychology.

for the most part, it is almost impossible for a hospital to have an embedded psychologist in their system - because of the above and also because their billing is so different. in general, they bill under mental health codes and there are different facility requirements that need to be established prior.

a private practice office of course is different and has a lot more flexibility in this manner. drusso will hopefully chime in.



in terms of what you can do - introduce the concept of pain catastrophizing. having a patient do a Pain Catastrophizing Scale can help solidify these concerns to the patient. obviously, she will think you are saying her pain is in her head and you should take the usual precautions that you are not implying this, and encourage her to consider seeing a counsellor to discuss further.
 
Members don't see this ad :)
i Know nothing about billing but I can’t imagine having one in your office would be a bad thing.

It would be very beneficial to the practice however.
 
drpainfree said:
just spent an hour with a young, female patient who was catastrophizing her cervical radiculopathy symptoms. my staff hated me because I kept them in the office at 6:30pm on Saturday afternoon.

while I feel pain psychology is an integral part of pain management, I'm not sure I'm doing the best job a patient deserves. I have sent patients out for psych therapy with psychologists who do my SCS psych clearance. my patients would always end up unhappy with their services.

Here's the question, any of you offers psych therapy in your office for pain management? We had them on staff in fellowship, but I have seen few private practices hiring pain psych on staff.

Is it really profitable to hire a psychologist or even psych therapist to come in once a week and talk to these patients about their insight, expectation, and coping skills, even co-manage their depression, anxiety, etc?

How do you bill for these services?

Thanks for the input.
Click to expand...

PhD/PsyD's don't pencil out. MSW's/LCSW's are cheaper and more controllable. Still, absent a juicy site-of-service differential, behavioral health in private practice is a loss leader service line. I've learned the hard way...
 
drusso said:
PhD/PsyD's don't pencil out. MSW's/LCSW's are cheaper and more controllable. Still, absent a juicy site-of-service differential, behavioral health in private practice is a loss leader service line. I've learned the hard way...
Click to expand...

Thanks for the input, drusso. do you mind I pm you about your experience? I'm not looking to make a profit on it, just so that I can offer the services to my patients and directly maintain the quality of services.
 
lobelsteve said:
Send to CSW. Less costly. Less mental health stigma for insurance or patient.

Shout out to Centerpoint Counseling in Woodstock Georgia.

it’s about time YOU got into counseling
Click to expand...

steve, without getting personal, do realize as a pain management physician, you do carry the hat of counseling if you are trying to maximize your treatment/management outcome. but then, what do I expect, you don't even think when you step into a procedure room, you are bound by all sets of standard expected in an operating room.
 
Ducttape said:
i send out to pain psych all the time. like literally, more referrals to psych than to even PT or rads.

most go to a counsellor, as Medicaid does not cover psychological treatment. of course, these are generally the patients that require actual psychology.

for the most part, it is almost impossible for a hospital to have an embedded psychologist in their system - because of the above and also because their billing is so different. in general, they bill under mental health codes and there are different facility requirements that need to be established prior.

a private practice office of course is different and has a lot more flexibility in this manner. drusso will hopefully chime in.



in terms of what you can do - introduce the concept of pain catastrophizing. having a patient do a Pain Catastrophizing Scale can help solidify these concerns to the patient. obviously, she will think you are saying her pain is in her head and you should take the usual precautions that you are not implying this, and encourage her to consider seeing a counsellor to discuss further.
Click to expand...

the particular patient knew she's catastrophizing. she even acknowledged her personality of "glass half empty"...she just couldn't stop crying, I meant crying, not tearing/sobbing...it was draining, but I just couldn't walk out of the room and left her crying...
 
drpainfree said:
steve, without getting personal, do realize as a pain management physician, you do carry the hat of counseling if you are trying to maximize your treatment/management outcome. but then, what do I expect, you don't even think when you step into a procedure room, you are bound by all sets of standard expected in an operating room.
Click to expand...
Dont lecture me kid.
 
I’ve been there. Give her some Kleenex, listen for a bit... but - as I’m learning every day - time is money. Ask the nurse to come in so she can talk to the patient. If you want, give the patient a little pat or hug (with the nurse as a witness)

If she can’t get in to see a pain psych, then send to counselor/ therapist. You can also suggest some self-help pain books/audiobooks available at libraries to start. Vidyalmala Burch and John Otis and Margaret Caudill are 3 good authors of self- help CBT books...
 
Ducttape said:
I’ve been there. Give her some Kleenex, listen for a bit... but - as I’m learning every day - time is money. Ask the nurse to come in so she can talk to the patient. If you want, give the patient a little pat or hug (with the nurse as a witness)

If she can’t get in to see a pain psych, then send to counselor/ therapist. You can also suggest some self-help pain books/audiobooks available at libraries to start. Vidyalmala Burch and John Otis and Margaret Caudill are 3 good authors of self- help CBT books...
Click to expand...

Thank you MUCH for the valuable advise.
 
no doubt, these patients are draining. i learned a while back that for MY sanity, i just simply cant listen that long. i give them some time, i give them my short motivational spiel, then i move on. im not a psychologist/psychiatrist, and dont want to be one. my experience with pain psych has not been a positive one. patients rarely attend, and when they do, they dont follow up. many cant find a local psych provider. most of the "providers" are there for a couple months at a time, then move on becuase they get paid bupkus. and i understand that it is an important part of a a multidisciplinary approach, yada yada yada.. until it gets reimbursed appropriately, patients will continue to see modest, if any benefit.

not sure why you are working on a saturday, much less until 6:30, but that is a horse of a different feather
 
drpainfree said:
Thanks for the input, drusso. do you mind I pm you about your experience? I'm not looking to make a profit on it, just so that I can offer the services to my patients and directly maintain the quality of services.
Click to expand...

Without a SOS d(f), the payment for mental health services stinks. That's why mental health professionals run super-lean micro-practices, share offices, do their own billing (or don't take insurance), etc. To make the juice worth the squeeze, you have to have a behaviorist cranking between 12-15 patient day under a worst case scenario of 50% government payer. My experience has been that most mental health professionals can't function at this pace without coming unglued. If you can't crack into getting a SOS d(f), then sometimes you can negotiate for a capitated per member per month compensation agreement. These are very hard to get.

You definitely want them to be a 1099 employee or straight productivity. You can't afford to have these people sitting around and surfing the web when their patients don't show. They need skin in the game.
 
Last edited:
Members don't see this ad :)
There's a high no show rate on pain psychology referrals, too. Very hard to make it work.

Group CBT for pain is an evidence-based treatment and you could run groups every month or two and refer all your psychologically complex patients to them, it's much easier to break even and there's less wear and tear on providers.
 
SeniorWrangler said:
There's a high no show rate on pain psychology referrals, too. Very hard to make it work.

Group CBT for pain is an evidence-based treatment and you could run groups every month or two and refer all your psychologically complex patients to them, it's much easier to break even and there's less wear and tear on providers.
Click to expand...

I've experimented with this too...try sitting in on a group CBT session with a room full of opioid tolerant chronic pain patients some time and tell me what you think...
 
My fellowship had 5 PhD Pain Psych ppl on staff, their own fellows, and that Pain Psych dept is arguably the best in the country...and it doesn't do anything tangible in terms of pt outcomes. Zero. Zilch. Nada. Waste of time. It is completely LAUGHABLE to say otherwise. The only thing they did was offer insight for stim or IT therapy.
 
I think every pain doctor should attend this 2 day course @ world-renowned Beck Institute, CBT for Pain:

CBT for Chronic Pain and Opioid Use | Beck Institute for Cognitive Behavior Therapy

Or at least send your staff for training (RN, NP, PA, etc.). Will end up saving you tons of hours in the long run, as helps you better recognize and manage this group of patients.

Stanford Psychologist Beth Darnall is one of the world's leaders on CBT for Pain. She has a lot of good resources too..
 
Last edited:
Blitz2006 said:
I think every pain doctor should attend this 2 day course @ Beck Institute, CBT for Pain:

CBT for Chronic Pain and Opioid Use | Beck Institute for Cognitive Behavior Therapy

Or at least send your staff for training (RN, NP, PA, etc.). Will end up saving you tons of hours in the long run, as helps you better recognize and manage this group of patients.

Stanford Psychologist Beth Darnall is one of the world's leaders on CBT for Pain. She has a lot of good resources too..
Click to expand...

This is a good course.
 
drusso said:
Without a SOS d(f), the payment for mental health services stinks. That's why mental health professionals run super-lean micro-practices, share offices, do their own billing (or don't take insurance), etc. To make the juice worth the squeeze, you have to have a behaviorist cranking between 12-15 patient day under a worst case scenario of 50% government payer. My experience has been that most mental health professionals can't function at this pace without coming unglued. If you can't crack into getting a SOS d(f), then sometimes you can negotiate for a capitated per member per month compensation agreement. These are very hard to get.

You definitely want them to be a 1099 employee or straight productivity. You can't afford to have these people sitting around and surfing the web when their patients don't show. They need skin in the game.
Click to expand...

what are some common cpt codes you would use to bill for these services? I need get some numbers first and think about feasibility of offering these services. I am looking for at least breaking even, not necessary much profit.
 
SSdoc33 said:
no doubt, these patients are draining. i learned a while back that for MY sanity, i just simply cant listen that long. i give them some time, i give them my short motivational spiel, then i move on. im not a psychologist/psychiatrist, and dont want to be one. my experience with pain psych has not been a positive one. patients rarely attend, and when they do, they dont follow up. many cant find a local psych provider. most of the "providers" are there for a couple months at a time, then move on becuase they get paid bupkus. and i understand that it is an important part of a a multidisciplinary approach, yada yada yada.. until it gets reimbursed appropriately, patients will continue to see modest, if any benefit.

not sure why you are working on a saturday, much less until 6:30, but that is a horse of a different feather
Click to expand...

Monday off, working on Sat to accommodate some younger patient's work schedule.
 
SeniorWrangler said:
There's a high no show rate on pain psychology referrals, too. Very hard to make it work.

Group CBT for pain is an evidence-based treatment and you could run groups every month or two and refer all your psychologically complex patients to them, it's much easier to break even and there's less wear and tear on providers.
Click to expand...

thank you for the suggestion. while personalized option is always the best and most effective, it sounds like a great option to get the program started. How do you go about billing/charging group therapy?
 
you cannot actually bill for psychologic counseling. there are separate CPT codes for mental health counseling and you have to be certified...

you can bill for pain treatment and incorporate some CBT teaching in to your pain treatment appointments. that would be billed under your usual CPT codes (99211-99215, etc.)

if I were you, I would talk to a pain psychologist or therapist and let them set up an office in your suite, with referrals from you (and elsewhere), and basically charge them rent. Let them bill on their own.
 
Ducttape said:
you cannot actually bill for psychologic counseling. there are separate CPT codes for mental health counseling and you have to be certified...

you can bill for pain treatment and incorporate some CBT teaching in to your pain treatment appointments. that would be billed under your usual CPT codes (99211-99215, etc.)

if I were you, I would talk to a pain psychologist or therapist and let them set up an office in your suite, with referrals from you (and elsewhere), and basically charge them rent. Let them bill on their own.
Click to expand...

I'm not talking about billing counseling myself.

Basically, I'm trying to find out if it's feasible to hire a therapist to do pain psych counseling in my office. I have found it's more headache to share an office with another clinician.
 
drpainfree said:
I'm not talking about billing counseling myself.

Basically, I'm trying to find out if it's feasible to hire a therapist to do pain psych counseling in my office. I have found it's more headache to share an office with another clinician.
Click to expand...

Just the basic behavioral health and psychotherapy codes. You'll have to PA any psych testing or neuropsych assessment. Also, if you hire a mental health professional you will likely need to get your contracts modified as some payers don't include mental health under the usual medical office CPT codes and contracts--they carve out behavioral health. You can't just employ a counselor and add them your group NPI in most cases despite all the lip-service given to mental health parity.

I'm not trying to dissuade you, but having in house psych is a pain in the arse on a lot of different levels: It's a lot of organizational fizz, fuss, and fiddle for very little ROI. It is nice to curb-side mental health or be able to do a quick lateral on patients who sneak by the usual screening mechanisms...it seems like next up and coming thing is hire naturopaths or chiropractors to do "wellness" work. Insurances are starting to pay for that more and more. Maybe look into that instead....
 
best way is to call a behavioral health therapist that is already out on his/her own and see how much they are paying for rent - and offer part of your office for less cost. the private practice people should know how to set up an office to see patients. again, I don't think it is easy at all to get a piece of what they charge - charging rent for them to do their stuff is infinitely easier.
 
drpainfree said:
I'm not talking about billing counseling myself.

Basically, I'm trying to find out if it's feasible to hire a therapist to do pain psych counseling in my office. I have found it's more headache to share an office with another clinician.
Click to expand...

In order to hit that bench mark of 12 behavioral health patients per day, you need to make sure that your counselor has a good personality and "people skills." That might seem obvious, but you'd be surprised. You definitely want to hang out with them for a while, go to a basketball game or something, before pitching them any offer...

Also, don't expect a hardcore CBT therapist to have a line out the door and be a barn burner with the patients in the waiting room. A good pain psychologists/therapist needs to have more than one kind of "schtick" to keep pain patients attention. After all, the end-user experience of CBT is about as riveting as tutoring your six-grader in algebra. It can be very, very repetitive: "Yes, my faulty automatic thoughts are triggering my catstrophizing schema and causing me to withdraw from pleasurable activities and friends..." It's a lot of white board, workbooks & worksheets, and HOMEWORK. It can feel like taking a class at the junior college. The typical chronic patient is usually not that engaged/activated or invested in their own self-development to benefit from CBT at the get-go. So, look for competency in other modalities: "Shame" and "Worthiness" are hot right now...especially in this #MeToo era. A good therapist who can get in touch with chronic pain patient's feelings of "Shame," "Worthiness," and "hidden trauma" will be a hit. You'll triple your Kleenex budget. EMDR also brings them in and lends itself to a higher volume practice...ditto for hypnosis...
 
Ducttape said:
not everything is fixed by the tip of a needle. chronic pain sure isn't.
Click to expand...

I know Beth, and if I felt that sitting down with her or any other pain psychologist was worthwhile I would have said so...
 
drusso said:
In order to hit that bench mark of 12 behavioral health patients per day, you need to make sure that your counselor has a good personality and "people skills." That might seem obvious, but you'd be surprised. You definitely want to hang out with them for a while, go to a basketball game or something, before pitching them any offer...

Also, don't expect a hardcore CBT therapist to have a line out the door and be a barn burner with the patients in the waiting room. A good pain psychologists/therapist needs to have more than one kind of "schtick" to keep pain patients attention. After all, the end-user experience of CBT is about as riveting as tutoring your six-grader in algebra. It can be very, very repetitive: "Yes, my faulty automatic thoughts are triggering my catstrophizing schema and causing me to withdraw from pleasurable activities and friends..." It's a lot of white board, workbooks & worksheets, and HOMEWORK. It can feel like taking a class at the junior college. The typical chronic patient is usually not that engaged/activated or invested in their own self-development to benefit from CBT at the get-go. So, look for competency in other modalities: "Shame" and "Worthiness" are hot right now...especially in this #MeToo era. A good therapist who can get in touch with chronic pain patient's feelings of "Shame," "Worthiness," and "hidden trauma" will be a hit. You'll triple your Kleenex budget. EMDR also brings them in and lends itself to a higher volume practice...ditto for hypnosis...
Click to expand...
This sounds like the third ring of hell
 
Ducttape said:
not everything is fixed by the tip of a needle. chronic pain sure isn't.
Click to expand...

Exactly.

The ironic part is, the more time you dedicate/advocate to pain psychology to patients that need it, indirectly results in more needle time for you.

So not only are you providing good care for your patient, but also freeing up your time to do other things.
 
Blitz2006 said:
Exactly.

The ironic part is, the more time you dedicate/advocate to pain psychology to patients that need it, indirectly results in more needle time for you.

So not only are you providing good care for your patient, but also freeing up your time to do other things.
Click to expand...

Has this been your personal experience? And if so, may I ask what the setting was that you made it work in (Hospital outpatient, private practice with in house psychologist, or refer out to an outside provider)? My practice is looking at hiring a pain psychologist. For context though, we are a private orthopedic practice. There is a PM&R guy who does a high volume of lumbar injections and RFAs, but I am the pretty much the only one in the practice doing stim, kypho, cervical injections, and nerve blocks, etc. Most of the practice is general ortho and sports med. I still haven’t gotten the hang of cutting off those people who really need counseling either which throws my schedule off a lot, so I’d love to be able to hand them an in house referral. I’m not doing any opioid management but I do have plenty of those fibro patients, people who want opioids, and people who are really bought in to their identity as chronic pain patients, who really need counseling more than injections.
 
drusso said:
PhD/PsyD's don't pencil out. MSW's/LCSW's are cheaper and more controllable. Still, absent a juicy site-of-service differential, behavioral health in private practice is a loss leader service line. I've learned the hard way...
Click to expand...

hey drrusso - did you try to hire a PhD/PsyD for a pain practice? We're thinking about it because our group cant get any of our Neurostimulation cases scheduled - we're all held up waiting for Psych clearance. Any words of advice?
 
InterventionMD45 said:
hey drrusso - did you try to hire a PhD/PsyD for a pain practice? We're thinking about it because our group cant get any of our Neurostimulation cases scheduled - we're all held up waiting for Psych clearance. Any words of advice?
Click to expand...

Same boat. I lean heavily on a couple of psychologists to "fast track" stim patients. The field needs to advocate for broader credentialing of behavioral health practitioners--the SCS should get together and offer a certificate/credential in psychological aspects of neuromodulation. Insurance companies won't let Master's level mental health practitioners do these assessments.
 
drusso said:
Same boat. I lean heavily on a couple of psychologists to "fast track" stim patients. The field needs to advocate for broader credentialing of behavioral health practitioners--the SCS should get together and offer a certificate/credential in psychological aspects of neuromodulation. Insurance companies won't let Master's level mental health practitioners do these assessments.
Click to expand...
Agreed! We're under pressure to wean/discontinue opioids by the state but we cant find anyone to see/clear these patients so that we can actually offer alternative treatments, like SCS or DRG, instead of pharmacological therapy. Not sure if it's a reimbursement issue, training issue or hassle-issue but there just arent PhD/PsyD to treat this patient population.
 
because most felt like paid shills for the stim companies. at least, the 3 that I have had direct discussions with felt that way.

I know you are well meaning, but you can always offer alternative treatments to opioids outside of SCS/DRG, and part of that treatment might be a better and more fulfilling role for psychologists than just approving SCS.
 
Ducttape said:
because most felt like paid shills for the stim companies. at least, the 3 that I have had direct discussions with felt that way.

I know you are well meaning, but you can always offer alternative treatments to opioids outside of SCS/DRG, and part of that treatment might be a better and more fulfilling role for psychologists than just approving SCS.
Click to expand...
I wont take that as an insult then.
Of COURSE we offer treatments beyond SCS/DRG...
 
Ducttape said:
because most felt like paid shills for the stim companies. at least, the 3 that I have had direct discussions with felt that way.

I know you are well meaning, but you can always offer alternative treatments to opioids outside of SCS/DRG, and part of that treatment might be a better and more fulfilling role for psychologists than just approving SCS.
Click to expand...

Do you know the data on CBT for chronic pain?
 
yes.

its about the same as regenerative medicine.

but less invasive, and no eyeballs are lost, cepting those rolling up in to disbeliever's heads.
 
but you could be wasting the patients with regen...


I see CBT as a way of making the patient as a better person as a whole, even if it does not alter pain perception and subsequent consequences
 
Ducttape said:
but you could be wasting the patients with regen...


I see CBT as a way of making the patient as a better person as a whole, even if it does not alter pain perception and subsequent consequences
Click to expand...

Show me the data...


Send to




Acta Psychiatr Scand. 2017 Sep;136(3):236-246. doi: 10.1111/acps.12713. Epub 2017 Feb 27.
Does psychotherapy work? An umbrella review of meta-analyses of randomized controlled trials.
Dragioti E1,2, Karathanos V1, Gerdle B2, Evangelou E1,3.
Author information
1Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece.2Department of Medical and Health Sciences, Pain and Rehabilitation Centre, Linköping University, Linköping, Sweden.3Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Abstract
OBJECTIVE:
To map and evaluate the evidence across meta-analyses of randomized controlled trials (RCTs) of psychotherapies for various outcomes.
METHODS:
We identified 173 eligible studies, including 247 meta-analyses that synthesized data from 5157 RCTs via a systematic search from inception to December 2016 in the PubMed, PsycINFO and Cochrane Database of Systematic Reviews. We calculated summary effects using random-effects models, and we assessed between-study heterogeneity. We estimated whether large studies had significantly more conservative results compared to smaller studies (small-study effects) and whether the observed positive studies were more than expected by chance. Finally, we assessed the credibility of the evidence using several criteria.
RESULTS:
One hundred and ninety-nine meta-analyses were significant at P-value ≤ 0.05, and almost all (n = 196) favoured psychotherapy. Large and very large heterogeneity was observed in 130 meta-analyses. Evidence for small-study effects was found in 72 meta-analyses, while 95 had evidence of excess of significant findings. Only 16 (7%) provided convincing evidence that psychotherapy is effective. These pertained to cognitive behavioural therapy (n = 6), meditation therapy (n = 1), cognitive remediation (n = 1), counselling (n = 1) and mixed types of psychotherapies (n = 7).
CONCLUSIONS:
Although almost 80% meta-analyses reported a nominally statistically significant finding favouring psychotherapy, only a few meta-analyses provided convincing evidence without biases.
© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
 
Big surprise — CBT has the best evidence.
This article like one of those analyses of “injections for back pain” that drive the ASIPP guys nuts.
 
You must log in or register to reply here.

Similar threads

C
Pain Block Trays
Replies
15
Views
807
Ferdog27
F
lobelsteve
Pain Sensitivity testing
Replies
1
Views
548
drusso
drusso
Z
Pain Fellowship
Replies
5
Views
2K
stsa84
stsa84
S
Favorite Pain Society
Replies
3
Views
1K
Status Sciaticus
Status Sciaticus
lobelsteve
Pain Surgeon?
2 3
Replies
133
Views
10K
drusso
drusso
Top