prescribing psychologists/NPs

[Sushirolls]

90 minutes
But most I believe spend 60 minutes

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[tr]

I think for the majority of cases a in-depth clinical interview with a competent clinician is all that is required to obtain an accurate diagnosis. I'm curious about outpatient psychiatrists, how long do you spend on an intake/90792?

I budget 90 minutes and if I use it all, which I usually do, I bill 99205 + 90833. If it is a simple case and we wrap it up in an hour I will bill 90792.

 

[clausewitz2]

I think for the majority of cases a in-depth clinical interview with a competent clinician is all that is required to obtain an accurate diagnosis. I'm curious about outpatient psychiatrists, how long do you spend on an intake/90792?

In our academic system the standard is an hour or so but I at least can get away with more when necessary. Not necessarily reflective of real world practice.

 

[nexus73]

I think for the majority of cases a in-depth clinical interview with a competent clinician is all that is required to obtain an accurate diagnosis. I'm curious about outpatient psychiatrists, how long do you spend on an intake/90792?

I take (get) 90 minutes at an employed position, and count myself extremely lucky to have time with patient and time to talk separately with family if needed. I've heard of clinics scheduling two initial appointments both an hour long and billing 90792 for each appointment. I'm not sure how you bill and document to capture 90792 at both encounters, but two 1 hour sessions sounds pretty good too.

 

[LadyHalcyon]

I find that if I am doing an intake for a psych eval for a complicated case, I can easily take every bit of 90 min. Of course it also depends upon how talkative the person is. But if they have multiple inpatient hospitalizations, a long history of substance abuse, substantial trauma history, were diagnosed with adhd, placed in special Ed classes, was suspended and expelled multiple times then yeah, I need an hour and a half. Now, there are some therapy clients where I feel 90% confident of their diagnosis within the first 20 min, sometimes even the first 5 (I kid, kinda.....)

Eta: Given the fact you take your time AND speak with family members I would definitely trust your diagnostic impressions. Maybe I'm blaming the clinicians when I should be blaming the systems

I take (get) 90 minutes at an employed position, and count myself extremely lucky to have time with patient and time to talk separately with family if needed. I've heard of clinics scheduling two initial appointments both an hour long and billing 90792 for each appointment. I'm not sure how you bill and document to capture 90792 at both encounters, but two 1 hour sessions sounds pretty good too.

 

[Merely]

I find that if I am doing an intake for a psych eval for a complicated case, I can easily take every bit of 90 min. Of course it also depends upon how talkative the person is. But if they have multiple inpatient hospitalizations, a long history of substance abuse, substantial trauma history, were diagnosed with adhd, placed in special Ed classes, was suspended and expelled multiple times then yeah, I need an hour and a half. Now, there are some therapy clients where I feel 90% confident of their diagnosis within the first 20 min, sometimes even the first 5 (I kid, kinda.....)

Eta: Given the fact you take your time AND speak with family members I would definitely trust your diagnostic impressions. Maybe I'm blaming the clinicians when I should be blaming the systems

Well to be clear, the answers you’re getting here are from top notch psychiatrists compared to the community standard. The people talking to you here are not the norm. The norm is probably 45 minute intakes (sometimes less) and generally poor quality as the standard of care compared to the top notch, insightful people we might have on this board.

 

[WisNeuro]

45 minute intakes would be an improvement for many.

 

[Stagg737]

90 minutes
But most I believe spend 60 minutes

I budget 90 minutes and if I use it all, which I usually do, I bill 99205 + 90833. If it is a simple case and we wrap it up in an hour I will bill 90792.

In our academic system the standard is an hour or so but I at least can get away with more when necessary. Not necessarily reflective of real world practice.

I take (get) 90 minutes at an employed position, and count myself extremely lucky to have time with patient and time to talk separately with family if needed. I've heard of clinics scheduling two initial appointments both an hour long and billing 90792 for each appointment. I'm not sure how you bill and document to capture 90792 at both encounters, but two 1 hour sessions sounds pretty good too.

I'm finding these responses interesting since the standardized ACGME interviews on "new" patients we're required to do on a year (bi-annually?) basis have a 30 minute time limit involved.

 

[Sushirolls]

I'm finding these responses interesting since the standardized ACGME interviews on "new" patients we're required to do on a year (bi-annually?) basis have a 30 minute time limit involved.

If you have a link on this, that would be interesting. I could see 30 minutes say for Primary Care, or sleep medicine, or cardiology, but definitely not psych.

 

[Stagg737]

If you have a link on this, that would be interesting. I could see 30 minutes say for Primary Care, or sleep medicine, or cardiology, but definitely not psych.

I'll try and find one. I know at our program we have to do 1 interview as interns and then 2 every other year and they're either ACGME requirements or to prepare us for an ACGME requirement (by having the exact same set up).

 

[calvnandhobbs68]

If you have a link on this, that would be interesting. I could see 30 minutes say for Primary Care, or sleep medicine, or cardiology, but definitely not psych.

So I think Stagg is talking about CSVs (which all residents have to do 3 of before the end of residency). My program typically gives us 30 minutes for the interview too but if you look at the actual ABPN document...

https://www.abpn.com/wp-content/uploads/2015/01/CSE-Psychiatry-2017.pdf

"The length of the evaluation will be determined by each residency program based on the competency components to be assessed. At a minimum, each evaluation session should last at least 45 minutes. The physician should be given a minimum of 30 minutes to conduct the psychiatric interview. Thereafter, he/she should have a minimum of 10-15 minutes to present the case. If the program has decided to assess additional competency components, the session may last longer. If appropriate, the evaluator may give feedback to the physician."

So it's really saying a MINIMUM of 30 minutes with 10-15 for the case presentation but then it gets kind of ambiguous because it says "IF the program has decided to assess ADDITIONAL competency components, the session MAY last longer". So I think most program interpret this as, if they're not assessing anything else besides whats on the CSV form it should last 30 minutes.

 

[LadyHalcyon]

Damn sampling errors

Well to be clear, the answers you’re getting here are from top notch psychiatrists compared to the community standard. The people talking to you here are not the norm. The norm is probably 45 minute intakes (sometimes less) and generally poor quality as the standard of care compared to the top notch, insightful people we might have on this board.

 

[DynamicDidactic]

Is there a general thought that psych testing is the gold standard for diagnosing? In my experience, it's a mixed bag. I only see adults so maybe the utility is more for kids.

No, psych testing is not the gold standard for diagnosing. Its a tool to help delineate a specific differential you already have in mind.

The term "psych testing" is an overly broad term. For diagnosing the gold standard would be using a structured, research-supported interview (the lack of reliability for unstructured interviews is staggering). Additional testing may be necessary if research-supported structured interviews (not the stuff agencies/individuals develop for themselves) are not conclusive.

 

[FlowRate]

The term "psych testing" is an overly broad term. For diagnosing the gold standard would be using a structured, research-supported interview (the lack of reliability for unstructured interviews is staggering). Additional testing may be necessary if research-supported structured interviews (not the stuff agencies/individuals develop for themselves) are not conclusive.

Do you have a favorite structured interview? Do you pay for them yourself?

 

[AcronymAllergy]

Do you have a favorite structured interview? Do you pay for them yourself?

Certainly not to speak for DynamicDidactic, but the SCID has been considered a go-to for many years; it's wide-ranging but a bit cumbersome, and it's generally pay-to-play (although I think there are exceptions). I used to frequently use the MINI, as it was both faster than the SCID and free, but the latter seems to no longer be the case.

Can also depend on if there are specific condition(s) in question, of course. E.g., the CAPS is a "gold standard" structured interview for PTSD.

 

[splik]

Can also depend on if there are specific condition(s) in question, of course. E.g., the CAPS is a "gold standard" structured interview for PTSD.

Im not a big fan of the CAPS because it is tedious to do and easy for people to overendorse symptoms. The key thing is that the patient needs to give very specific examples of their symptoms that ring true for genuine PTSD. Even for forensic evals, instead of doing the CAPS I just use the PCL-5 and then for the items they endorse 3 or 4 on focus on teasing out specific examples of symptoms than can't easily be faked. That along with some kind of symptom validity testing can be very helpful. the morel emotional numbing test is one such example for PTSD. but even the MMPI-2's validity scales can be very helpful.

 

[Armadillos]

Certainly not to speak for DynamicDidactic, but the SCID has been considered a go-to for many years; it's wide-ranging but a bit cumbersome, and it's generally pay-to-play (although I think there are exceptions). I used to frequently use the MINI, as it was both faster than the SCID and free, but the latter seems to no longer be the case.

Can also depend on if there are specific condition(s) in question, of course. E.g., the CAPS is a "gold standard" structured interview for PTSD.

I don’t really get the point of paying for stuff like the Mini, IIRC it’s literally just reading someone the DSM criteria??

 

[AcronymAllergy]

I don’t really get the point of paying for stuff like the Mini, IIRC it’s literally just reading someone the DSM criteria??

Not far off, although it does have some examples of additional and/or probing questions, and spells the decision tree algorithms out for you rather than you needing to keep track of them yourself. It also has empirical support, which can be beneficial in some settings.

RE: the CAPS, agree that the potential for over-endorsement exists, which is true for pretty much every structured clinical interview. And yeah, it's long. I do appreciate the specificity of the questions, and the differentiation between the different elements of symptomology. And to be fair, it was developed for clinical rather than forensic use, although certainly the potential for over-reporting is just as high in many clinical settings as it is forensically. It does have what I call the "trustworthiness" item the clinician can use to speak to the validity of the responses, but this is of course very limited. I typically see it used in research (much like the SCID) and in some PTSD-specific clinics with more complex cases. I'm not a PTSD expert, but would I say the CAPS is needed in most cases? Probably not.

 

[psyguru]

As an expert witness I am not concerned with NP forensic experts.. even if there is a case involving np malpractice where they would get a np expert, they would also get a psychiatrist.

 

[DynamicDidactic]

Do you have a favorite structured interview? Do you pay for them yourself?

I was lucky enough to never have to pay for one myself. A lot of my interviewing was done in a clinical research capacity and the SCID was very popular.

It took a little bit of getting used to but once you get it, you get it. I think people get lazy and the structured interview keeps you a bit more honest and less likely to drift based on other factors. So, even if people's experience with the CAPS is that it can lead to overendorsing, it is likely much more reliable (notice, not valid) than unstructured interviews.

I used to do the SCID depression modules, the HAM-D, and the BDI and it was interesting to see divergence at times. Much easier to score high/low on the HAM-D and still meet criteria with the SCID.