Private practice earnings

[liquidshadow22]

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I have never billed a 99203, mostly 99204 and some 99205. I despise insurance companies. The letter was a threat to downcode or Ill make trouble for you.

when would you use those codes as opposed to a 90792?

 

[liquidshadow22]

Do insurance companies ever do reviews of notes for determining out of network reimbursement for superbills submitted by pts in a cash practice?

bump

 

[TexasPhysician]

What would be standard rate in your area for two an hour?

$200-300/hr

 

[TexasPhysician]

How often that you could actually do 99214+90833? Is there a possibility of more audits from insurances?

You are going to be audited no matter what.

 

[AD04]

You are going to be audited no matter what.

I schedule 30 minutes for follow ups and I bill most of my follow up as 99214+90833. What will happen in an audit if my notes do meet the billing criteria (e.g. MDM, comprehensiveness of exam, time spent in therapy)?

If nothing, do insurances send those "you may be audited letter" to get physicians to undercode?

 

[AD04]

All my follow ups are 30 minutes, mostly 99214 without any add on codes and I just get a letter from some company bcbs hired saying I bill more complexity than my peers and they will be continuing to follow me and possible ask for chart review

Did the letter ask you why you are billing for less add-on therapy codes compared to your peers?

 

[TexasPhysician]

I schedule 30 minutes for follow ups and I bill most of my follow up as 99214+90833. What will happen in an audit if my notes do meet the billing criteria (e.g. MDM, comprehensiveness of exam, time spent in therapy)?

If nothing, do insurances send those "you may be audited letter" to get physicians to undercode?

Nothing. Private insurances would love for you to undercode. Many physicians are not well-versed in coding to maximize revenue, so a lot of poor coding is mixed to get their averages.

They use the averages to second guess yourself. They aren’t spending their time doing big audits on practices with mostly 99213’s to verify accuracy.

Additionally any mistakes on small chart reviews or audits can lead to mass audits and reimbursement pull-backs. You can’t afford a “poor documentation day”. Accuracy is vitally important in the insurance world.

 

[Attending1985]

Did the letter ask you why you are billing for less add-on therapy codes compared to your peers?

I do use the 90833 but only if I’m doing a 60 minute appointment so I say 25 minutes for the 99214 and 35 minutes for psychotherapy

 

[Attending1985]

when would you use those codes as opposed to a 90792?

I’ve never coded a 90792

 

[brosa]

I have a question. Is there a maximum limit of NPs/PAs one can supervise? In theory, can a psychiatrist run a successful practice just by supervising those midlevels?

 

[TexasPhysician]

I have a question. Is there a maximum limit of NPs/PAs one can supervise? In theory, can a psychiatrist run a successful practice just by supervising those midlevels?

Yes, state regulated.

 

[Candidate2017]

when would you use those codes as opposed to a 90792?

99205 is new 60 minutes, and reimburses more than 90792 from what I've seen. 99204 is new 45 minutes, and reimburses less.

 

[Candidate2017]

I have a question. Is there a maximum limit of NPs/PAs one can supervise? In theory, can a psychiatrist run a successful practice just by supervising those midlevels?

The large practices in my area have mostly psychiatrists and just a few NPs, and most are psychologist-owned. There are not a lot of good NPs to hire. They are inefficient, see fewer patients, and usually are out of their league. It seems easier to plug in psychiatrists that can operate independently and take a % of their collections. The problem is finding psychiatrists who want to work full time.

 

[Candidate2017]

I do use the 90833 but only if I’m doing a 60 minute appointment so I say 25 minutes for the 99214 and 35 minutes for psychotherapy

90833 add-on only requires 16 minutes of therapy as part of the overall visit. A 25 minute visit can legitimately hit requirements for a 99214 complexity + 16 min therapy.

Some PP people tell me they do three 20 minute visits an hour, usually billing them as 99214 + 90833, without any insurance pushhback.

 

[Attending1985]

90833 add-on only requires 16 minutes of therapy as part of the overall visit. A 25 minute visit can legitimately hit requirements for a 99214 complexity + 16 min therapy.

Some PP people tell me they do three 20 minute visits an hour, usually billing them as 99214 + 90833, without any insurance pushhback.

My understanding from the APA website and my employer is that it requires 30 minutes of psychotherapy.

 

[TexasPhysician]

My understanding from the APA website and my employer is that it requires 30 minutes of psychotherapy.

They are incorrect.

 

[Attending1985]

They are incorrect.

Well good to know maybe my employer is being cautious. I guess considering I’m getting these letters from 99214s maybe that’s why.

 

[liquidshadow22]

I’ve never coded a 90792

90833 add-on only requires 16 minutes of therapy as part of the overall visit. A 25 minute visit can legitimately hit requirements for a 99214 complexity + 16 min therapy.

Some PP people tell me they do three 20 minute visits an hour, usually billing them as 99214 + 90833, without any insurance pushhback.

Three visits an hr for this coding shiuld reimburse $600 an hour, no?

 

[hamstergang]

My understanding from the APA website and my employer is that it requires 30 minutes of psychotherapy.

Every billing code with a time just requires that you are closer to that time than another time. So, 90833 is listed as 30 minutes and 90836 is 45 minutes. Therefore, you can bill 90833 for 16-37 minutes as 16 is closer to 30 than to 0 and 37 is closer to 30 than to 45.

 

[clausewitz2]

Every billing code with a time just requires that you are closer to that time than another time. So, 90833 is listed as 30 minutes and 90836 is 45 minutes. Therefore, you can bill 90833 for 16-37 minutes as 16 is closer to 30 than to 0 and 37 is closer to 30 than to 45.

I still don't get how people are routinely billing three +90833s per hours with a straight face/ without raising red flags. If you are spending only 4 minutes per patient on e&m in what world are you making meaningful medical decisions?

 

[michaelrack]

"How is the depression doing? Any side effects to the zoloft? How are you sleeping? " a 99213 in a stable patient in 4 minutes (combined with 16 minutes psychotherapy) is doable.... 99214 in 4 minutes is a little harder to justify

 

[clausewitz2]

"How is the depression doing? Any side effects to the zoloft? How are you sleeping? " a 99213 in a stable patient in 4 minutes (combined with 16 minutes psychotherapy) is doable.... 99214 in 4 minutes is a little harder to justify

Thank you, I can sort of see how that might work. I would feel like an incredible putz doing it, but can see it. Frankly hadn't occured to me to assess someone's depression with a single question without follow-up.

 

[michaelrack]

Thank you, I can sort of see how that might work. I would feel like an incredible putz doing it, but can see it. Frankly hadn't occured to me to assess someone's depression with a single question without follow-up.

Well, you're really doing a lot of the assessment during the psychotherapy part of the visit.

Now just doing 4 minute follow up alone ( without the subsequent psychotherapy) is bad care

 

[tr]

99214 is supposed to be the equivalent complexity of a 25 min med mgmt visit. It's not realistic to claim to manage this level of medical complexity and also provide 16+ min psychotherapy in a 20 min visit, regardless of how quickly you can recite SIGECAPS.

I usually book 30 min follow ups which I bill either as 99214 alone or as 99213+90833.

 

[calvnandhobbs68]

All my follow ups are 30 minutes, mostly 99214 without any add on codes and I just get a letter from some company bcbs hired saying I bill more complexity than my peers and they will be continuing to follow me and possible ask for chart review

I've seen this on the facebook groups for psych and heard it myself from others...apparently they actually followup on these extremely rarely. It's basically a scare tactic to get you to downcode that's super cheap for them to send out. Resource allocation for the system identifying higher billers, printing out 1000 letters and mailing them is almost nothing and easily made up if they can scare 1-2 doctors into downcoding 10% of their charts from 99204/99214 to 99203/99213 for the next year. Having an actual person review charts for these 1000 doctors is a totally different story.

So in short, I wouldn't sweat it. Most doctors just toss these in the trash.

 

[Candidate2017]

I still don't get how people are routinely billing three +90833s per hours with a straight face/ without raising red flags. If you are spending only 4 minutes per patient on e&m in what world are you making meaningful medical decisions?

Routinely doing 20 minute 99214 + 90833 seems questionable. But, looking at E&M University's website, it appears possible to hit moderate decision making criteria with regard to problem points (1 new or 3 stable, or some combination of worsening problem), and risk points (2 chronic illnesses).

Still, I wouldn't want to do 3 visits/hour all day long. The PP people doing this seem to run late, get more phone calls, etc (turning a 20 minute visit into 25-30 minutes anyway). Whereas my 30 minute residency slots allow wiggle room to keep my schedule on time, finish notes, address concerns in session, and keep patients happy. I don't know if I will change my tune in the real world where no-shows dent the bottom line.

But for large practice owners here, I see how it economically behooves them to have their psychiatrists do 20 minute 99214 + 90833. They do very well and dominate the market (they are usually the only places that can schedule new patients quickly). I don't doubt their resources to lawyer up against any insurance resistance to their billing practices and/or threaten to drop the insurance. In any event, their practice model aligns well with insurance: quick access/high volume, satisfying minimum standard of care.

 

[splik]

I still don't get how people are routinely billing three +90833s per hours with a straight face/ without raising red flags. If you are spending only 4 minutes per patient on e&m in what world are you making meaningful medical decisions?

Two points here. It is definitely straight up sketchy to be doing 3x 99214+90833 per hour because it is not even possible to spend 4 mins on E&M for each patient (especially for in person visits, it just isn't happening). You are going to be losing minutes in between patients etc, so it is going to work out as each visit being 18 mins or less more likely. The other thing is the median RVUs for psychiatrists working on wRVU is a little over 3600. Based on this coding for all visits at a rate of 3/hr it would require you working 10hrs per week to get the median for a full time psychiatrist. This is another measure of how this would cast you as a significant outlier from your colleagues and raise a red flag.

It is however possible to do 4 minutes of E&M if you are spending additional time with psychotherapy. This is because, although it is required that psychotherapy be separately identifiable from E&M service, it is recognized it is impossible for the psychotherapy portion not to influence the E&M portion. There is nothing to stop you using information from the psychotherapy portion to direct your E&M portion with regards to diagnosis and management. Finally, I strongly advise anyone who is using a small amount of E&M time to use measurement-based practice. You are going to have a more compelling case in face of an audit if you are using scales like the PHQ-9, GAD-7, PCL-5, ADHD-SRS etc and tracking progress. This is good practice for everyone actually because payors want to see their are clear goals for treatment, that you are measuring and tracking said goals, and they are influencing your management.

[I do consulting and auditing for psychiatry practices related to coding/billing to help practices maximize revenue and maintain compliance with regards to documentation and also do insurance appeals for coverage denials. The above is just my approach and an individual payor may have their own take on this.]

 

[clausewitz2]

Two points here. It is definitely straight up sketchy to be doing 3x 99214+90833 per hour because it is not even possible to spend 4 mins on E&M for each patient (especially for in person visits, it just isn't happening). You are going to be losing minutes in between patients etc, so it is going to work out as each visit being 18 mins or less more likely.

It is however possible to do 4 minutes of E&M if you are spending additional time with psychotherapy. This is because, although it is required that psychotherapy be separately identifiable from E&M service, it is recognized it is impossible for the psychotherapy portion not to influence the E&M portion. There is nothing to stop you using information from the psychotherapy portion to direct your E&M portion with regards to diagnosis and management. Finally, I strongly advise using a small amount of E&M time to use measurement-based practice. You are going to have a more compelling case in face of an audit if you are using scales like the PHQ-9, GAD-7, PCL-5, ADHD-SRS etc and tracking progress. This is good practice for everyone actually because payors want to see their are clear goals for treatment, that you are measuring and tracking said goals, and they are influencing your management.

[I do consulting and auditing for psychiatry practices related to coding/billing to help practices maximize revenue and maintain compliance with regards to documentation and also do insurance appeals for coverage denials. The above is just my approach and an individual payor may have their own take on this.]

I have taken advantage of Luminello's ability to create custom rating scales and questionnaires to build out a large number of public domain screeners/scales (PHQ-9, GAD-7, OCI-R, ESS, Glasgow antipsychotic side effect scale, antidepressant side effect inventory, MDQ, PDQ-B, ASEX to track SSRI sexual dysfunction). Everyone gets sent the ones that are appropriate to their patient portal before every appointment. Most people actually fill them out in advance, so I actually end up with a good amount of data for most of my folks! Glad to hear it's something that will help with potential audits.

EDIT: also do an ACE plus with anyone wanting treatment for ADHD who wasn't diagnosed as a kid and has been on stimulants for ages. I don't use the ADHD-SRS much but maybe I should. I also track weight/BMI for anyone with a significant ED hx who is experiencing any kind of appetite disturbance.

 

[Attending1985]

I've seen this on the facebook groups for psych and heard it myself from others...apparently they actually followup on these extremely rarely. It's basically a scare tactic to get you to downcode that's super cheap for them to send out. Resource allocation for the system identifying higher billers, printing out 1000 letters and mailing them is almost nothing and easily made up if they can scare 1-2 doctors into downcoding 10% of their charts from 99204/99214 to 99203/99213 for the next year. Having an actual person review charts for these 1000 doctors is a totally different story.

So in short, I wouldn't sweat it. Most doctors just toss these in the trash.

Yeah I was a little freaked out that I was going to get audited or something and I’m not sure my documentation is always 100%. However I see all 99214s for at least 25 minutes so I think I’m good. Based on this thread I know now I’m significantly under billing by not using 90833 on a regular basis.

 

[splik]

I don't use the ADHD-SRS much but maybe I should.

I'm not a fan since patients can obviously overendorse things, I was just giving examples of commonly used scales. It might be one measure of response to treatment but I would be more inclined to get specific examples from the patient of how their functioning has changed with treatment. I wouldn't use it for diagnosis except perhaps as one data point to take into context. The ACE plus is an excellent tool for a semi-structured diagnostic interview. I use the DIVA-5 as part of a comprehensive evaluation. The ACE plus is good because it specifically gets at risk factors, relevant medical problems, and associated comorbidities. It drives me nuts when someone sees a psychologist for an evaluation and all they do is the Connors and don't bother getting a full social and developmental history, substance use history, and considering any medical or psychiatric comorbidities or learning difficulties. Round here there are psychologists marketing themselves as doing these evals for cash so people can get stimulants elsewhere from their PCP or a psychiatrist and they don't do a full diagnostic eval. Of course most psychiatrists don't seem to take a very comprehensive approach to assessment of these patients either alas.

 

[nrmp]

Routinely doing 20 minute 99214 + 90833 seems questionable. But, looking at E&M University's website, it appears possible to hit moderate decision making criteria with regard to problem points (1 new or 3 stable, or some combination of worsening problem), and risk points (2 chronic illnesses).

Still, I wouldn't want to do 3 visits/hour all day long. The PP people doing this seem to run late, get more phone calls, etc (turning a 20 minute visit into 25-30 minutes anyway). Whereas my 30 minute residency slots allow wiggle room to keep my schedule on time, finish notes, address concerns in session, and keep patients happy. I don't know if I will change my tune in the real world where no-shows dent the bottom line.

But for large practice owners here, I see how it economically behooves them to have their psychiatrists do 20 minute 99214 + 90833. They do very well and dominate the market (they are usually the only places that can schedule new patients quickly). I don't doubt their resources to lawyer up against any insurance resistance to their billing practices and/or threaten to drop the insurance. In any event, their practice model aligns well with insurance: quick access/high volume, satisfying minimum standard of care.

Can patient complaint to their insurance for any inappropriate billing? How can you do 20 or 30 minute session when someone with ADHD is completely stable on single medication and bill for 99214+90833 or 99213+90833? Reading at all these replies I think I underbill as well mostly using 99214's except few visits here and there where I actually spent more time talking/advise as considering therapy and would put add-on code. I am wondering if patients ever made a big complaint anywhere about this type billing practice where people bill 99214+90833 for 20 min visit?

 

[clausewitz2]

Can patient complaint to their insurance for any inappropriate billing? How can you do 20 or 30 minute session when someone with ADHD is completely stable on single medication and bill for 99214+90833 or 99213+90833? Reading at all these replies I think I underbill as well mostly using 99214's except few visits here and there where I actually spent more time talking/advise as considering therapy and would put add-on code. I am wondering if patients ever made a big complaint anywhere about this type billing practice where people bill 99214+90833 for 20 min visit?

So it is important to note that just being generally pleasant and giving advice is not psychotherapy. I never bill a psychotherapy add-on unless I am making some intervention or using some technique identifiable as belonging to a specific therapy modality. I can then document the use of that technique or intervention. This works better with some approaches than others.

 

[Stagg737]

99205 is new 60 minutes, and reimburses more than 90792 from what I've seen. 99204 is new 45 minutes, and reimburses less.

To add on to this, it's also generally easier to know you're hitting necessary criteria for 90792 than to figure out mid-interview if you're getting all the point necessary to move up to the 99205 (if you're not billing based on time). Our program just does 90792 for all new patients to keep things more simple.

Some PP people tell me they do three 20 minute visits an hour, usually billing them as 99214 + 90833, without any insurance pushhback.

My question here would be how many patients are no-showing and how often are they actually seeing 3 pts/hr? Having 12 patients scheduled for a morning (4 hours) can easily turn into 8-10 in some places, which would make that practice more reasonable.

Can patient complaint to their insurance for any inappropriate billing?

They can and I've had some patients (and a family member) do this, but I've only seen this done when the patient was claiming that something they were billed for wasn't done (patient in ER claims doc never did a physical exam, labs weren't ordered, etc). I think an incredibly small number of patients would be knowledgeable enough about billing to complain about potentially being upcoded and even less would actually file a complaint, but I guess it is possible.

So it is important to note that just being generally pleasant and giving advice is not psychotherapy. I never bill a psychotherapy add-on unless I am making some intervention or using some technique identifiable as belonging to a specific therapy modality. I can then document the use of that technique or intervention. This works better with some approaches than others.

Side note to the bolded, I've seen notes from certain physicians who write something along the lines of "Supportive psychotherapy with active listening provided" in pretty much every note they write. I rotated with one or two of them while in med school, and they didn't seem to have any issues with getting reimbursed or being audited. While the bold is certainly true from a clinical/therapeutic perspective, what passes as psychotherapy in the eyes of insurance companies can be pretty pathetic.

 

[brosa]

I think it is easy to tell what is therapy/what is not with CBT, but psychodynamic? If you train a psychiatrist in psychodynamics, I don't think you can "turn it off" during a 30-45 min appointment. I mean, it's kinda imbued lol

So for me it makes sense.

 

[psychacad]

I think it is easy to tell what is therapy/what is not with CBT, but psychodynamic? If you train a psychiatrist in psychodynamics, I don't think you can "turn it off" during a 30-45 min appointment. I mean, it's kinda imbued lol

So for me it makes sense.

Psychodynamically trained psychiatrists tend to object to a strict separation between "therapy" and "medication management", and I think this is the correct approach.

 

[clausewitz2]

Psychodynamically trained psychiatrists tend to object to a strict separation between "therapy" and "medication management", and I think this is the correct approach.

That's great. Next steps:

a) convince CMS to change the requirement that psychotherapy and E&M services be identifiably separate for reimbursement for both
b) design a rule to cover this that doesn't let people stack 16 minute med appointments on each other forever and justify their description of seroquel dosing as constituting "solution-focused psychotherapy"

 

[psychacad]

That's great. Next steps:

a) convince CMS to change the requirement that psychotherapy and E&M services be identifiably separate for reimbursement for both
b) design a rule to cover this that doesn't let people stack 16 minute med appointments on each other forever and justify their description of seroquel dosing as constituting "solution-focused psychotherapy"

The post was referencing 30-45 min appointments, so none of that is necessary. You can't really turn on/off therapy like you're turning a light switch, especially if you're operating in a dynamic framework, but that is entirely dependent on one's approach.

 

[clausewitz2]

The post was referencing 30-45 min appointments, so none of that is necessary. You can't really turn on/off therapy like you're turning a light switch, especially if you're operating in a dynamic framework, but that is entirely dependent on one's approach.

You're not wrong from a clinical and theoretical perspective. My point was a strictly regulatory one. As a fact of the matter if you can't point to a difference between your E&M and psychotherapy bits of the visit, you get paid for one or the other, not both. Them's the rules.

Maybe you want to change that. Fair enough. Thing is, you make it possible to double count, and pretty soon, coming to an NP stimulant/benzo factory near you, the 16 minute appointment slot, all day, every day! Bill for two different codes all together with literally the minimum possible amount of thought or effort. I think is is pretty cheeky to bill three 90833s an hour as a matter of course but at least they have to pretend they're being thoughtful about things under the current system.

 

[brosa]

"Doctor, thank you so much for everything you told me last appointment... it made me think so much about my relationship with my husband. Do you think he loves me?"

-alarm goes on-

"Sorry, 16min of therapy are over, do you want to increase the Zoloft dosage?"
"I don't know, I want to talk about my husband doctor"
"Ok, let's go 150mg. Come back in four weeks."
"But doctor..."
"200mg then, now leave"

That would be an interesting approach.

 

[Candidate2017]

Can patient complaint to their insurance for any inappropriate billing? How can you do 20 or 30 minute session when someone with ADHD is completely stable on single medication and bill for 99214+90833 or 99213+90833? Reading at all these replies I think I underbill as well mostly using 99214's except few visits here and there where I actually spent more time talking/advise as considering therapy and would put add-on code. I am wondering if patients ever made a big complaint anywhere about this type billing practice where people bill 99214+90833 for 20 min visit?

I'm going to guess patients don't complain about billing codes but will complain about not being prescribed their controlled sub of choice.

A stable patient with a single dx of ADHD, who comes in just to pick up a script, is a 99213. They should be sent to their peds or PCP. Generally though, ADHD usually presents with a host of other comorbidities, and 3 stable diagnoses (sometimes 2) can hit 99214 criteria for medical decision making/risk. The history and PE requirement s 99214 should always be hit in a decent note.

 

[Candidate2017]

My question here would be how many patients are no-showing and how often are they actually seeing 3 pts/hr? Having 12 patients scheduled for a morning (4 hours) can easily turn into 8-10 in some places, which would make that practice more reasonable.

Side note to the bolded, I've seen notes from certain physicians who write something along the lines of "Supportive psychotherapy with active listening provided" in pretty much every note they write. I rotated with one or two of them while in med school, and they didn't seem to have any issues with getting reimbursed or being audited. While the bold is certainly true from a clinical/therapeutic perspective, what passes as psychotherapy in the eyes of insurance companies can be pretty pathetic.

I'm running close to zero no-shows with the transition to telepsych. So I don't doubt these big practices are rolling through 24 per day and from the incomes they've alluded to me.

Insurance never cared about therapy. They only care about the cheapest option that somewhat works. They've realized their push for 15 min med-only checks, combined with cheap social worker "therapy", isn't as cost-effective as a 20/25/30 min visit with a psychiatrist whom patients feel listen and spend time with them. You can view the 90833 add-on code as merely a calculated, pragmatic carrot used by insurance/Medicare to discourage 15 min med checks and lure psychiatrists back to taking insurance. The carrot does work... I plan to take insurance seeing two an hour, combined med + therapy. Without the add-on, a cash practice makes much more financial sense.

 

[nrmp]

I'm going to guess patients don't complain about billing codes but will complain about not being prescribed their controlled sub of choice.

A stable patient with a single dx of ADHD, who comes in just to pick up a script, is a 99213. They should be sent to their peds or PCP. Generally though, ADHD usually presents with a host of other comorbidities, and 3 stable diagnoses (sometimes 2) can hit 99214 criteria for medical decision making/risk. The history and PE requirement s 99214 should always be hit in a decent note.

Have you had any concerns from patient with high deductible plans which majority does and ends up paying out of pocket for 99214+90833 for 20-30 min visit?

 

[nrmp]

I'm running close to zero no-shows with the transition to telepsych. So I don't doubt these big practices are rolling through 24 per day and from the incomes they've alluded to me.

Insurance never cared about therapy. They only care about the cheapest option that somewhat works. They've realized their push for 15 min med-only checks, combined with cheap social worker "therapy", isn't as cost-effective as a 20/25/30 min visit with a psychiatrist whom patients feel listen and spend time with them. You can view the 90833 add-on code as merely a calculated, pragmatic carrot used by insurance/Medicare to discourage 15 min med checks and lure psychiatrists back to taking insurance. The carrot does work... I plan to take insurance seeing two an hour, combined med + therapy. Without the add-on, a cash practice makes much more financial sense.

Seems like 90833 add on is working well for you with no major concerns from insurances. Need some guidance regarding what exactly would you really consider as therapy portion where if it's done with E&M and no particular measured goals? Do you document more details about therapy or it's mainly 1-2 lines? How do you document time spent on therapy (is it just total minutes or separate start and stop times which is very impractical but in my state medicare is requiring start/stop times)?

 

[tr]

Seems like 90833 add on is working well for you with no major concerns from insurances. Need some guidance regarding what exactly would you really consider as therapy portion where if it's done with E&M and no particular measured goals? Do you document more details about therapy or it's mainly 1-2 lines? How do you document time spent on therapy (is it just total minutes or separate start and stop times which is very impractical but in my state medicare is requiring start/stop times)?

Note header includes:
Start time: 00:00
End time: 00:00
20 minutes psychotherapy (documentation of content here: e.g., "coached session Calm Breathing," "counseling on sleep hygiene," "brief supportive," etc.)

I usually have some mention of the psychotherapy content in 1-2 sentences in the body of the note as well (e.g., "Sleep hygiene marginal, bedtime/waketime variable, often uses screens before bed. Elements of basic sleep hygiene were discussed, including regular bedtime/wake time, AM sun exposure, daytime exercise, avoidance of late-day caffeine, use of blue light blocker for any necessary PM screen time")


(PS please don't tell me sleep hygiene isn't psychotherapy, if I did a session of CBTi in which 20 min were sleep hygiene I'd bill the whole thing as a 90837)

 

[WisNeuro]

(PS please don't tell me sleep hygiene isn't psychotherapy, if I did a session of CBTi in which 20 min were sleep hygiene I'd bill the whole thing as a 90837)

I wish more people would do sleep hygiene, and that patients would take it more seriously. It would eliminate or at least significantly ameliorate a good portion of the concerns they present with, across disciplines.

 

[calvnandhobbs68]

(PS please don't tell me sleep hygiene isn't psychotherapy, if I did a session of CBTi in which 20 min were sleep hygiene I'd bill the whole thing as a 90837)

Sleep hygiene is therapy, we have psychologists in the sleep medicine department who bill entire 60 minute therapy visits just talking about sleep hygiene with patients.

 

[clausewitz2]

I wish more people would do sleep hygiene, and that patients would take it more seriously. It would eliminate or at least significantly ameliorate a good portion of the concerns they present with, across disciplines.

And if you take a good sleep history every. single. time you encounter someone with any kind of sleep complaint, you'd be surprised how often you catch narcolepsy or serious RLS, which is great because as physicians we totally can treat those things. It's like with migraines, if you can actually do something that works and is effective, you instantly win a ginormous amount of trust.

Also, no patient ever needed to be persuaded that their problems sleeping were significant or of relevance to their life.

 

[clausewitz2]

Note header includes:
Start time: 00:00
End time: 00:00
20 minutes psychotherapy (documentation of content here: e.g., "coached session Calm Breathing," "counseling on sleep hygiene," "brief supportive," etc.)

I usually have some mention of the psychotherapy content in 1-2 sentences in the body of the note as well (e.g., "Sleep hygiene marginal, bedtime/waketime variable, often uses screens before bed. Elements of basic sleep hygiene were discussed, including regular bedtime/wake time, AM sun exposure, daytime exercise, avoidance of late-day caffeine, use of blue light blocker for any necessary PM screen time")


(PS please don't tell me sleep hygiene isn't psychotherapy, if I did a session of CBTi in which 20 min were sleep hygiene I'd bill the whole thing as a 90837)

Mais non! I routinely use this dot phrase for my add-ons:

"Separate from evaluation and management portion of encounter, psychotherapy was performed for XX minutes encompassing individual CBT-I approach provided with a focus on identification of patterns of sleep and environmental/behavioral factors contributing to insomnia, psychoeducation regarding sleep drive, and development and adjustment of individualized sleep schedule with emphasis on sleep restriction and stimulus control."

 

[tr]

And if you take a good sleep history every. single. time you encounter someone with any kind of sleep complaint, you'd be surprised how often you catch narcolepsy or serious RLS, which is great because as physicians we totally can treat those things.

You treat RLS? Neuro told me that ropinirole and pramipexole are tricky to work with so unless Fe or gabapentin works I usually refer to them. I rather refer to sleep med for narcolepsy too.

Also, no patient ever needed to be persuaded that their problems sleeping were significant or of relevance to their life.

Yeah but plenty of them are difficult to convince that their bedtime phone habit, afternoon nap, or cocktail hour is the source of the problem.

I like your dot phrase, it's better than mine. Might steal it

 

[clausewitz2]

You treat RLS? Neuro told me that ropinirole and pramipexole are tricky to work with so unless Fe or gabapentin works I usually refer to them. I rather refer to sleep med for narcolepsy too.

I am reasonably comfortable with pramipexole and sometimes have used it (way different dosing, obviously) for depression. RLS wise just slowly slowly, always track progress quantitatively in some way, and have a plan for what to do if you start getting augmentation, even if that is just 'temporize until referral'.

My personal referral thresholds for sleep stuff:

Narcolepsy - stimulants/modafinil at sane doses aren't getting job done and/or cataplexy not responding to sertonergic agents I'm familiar with. Also I don't f with GHB.

RLS/PLMD- dopamine agonists don't touch it and it probably needs methadone or something equally dramatic

Kleine-Levin - oh h*ll no

Free-running - see above

Yeah but plenty of them are difficult to convince that their bedtime phone habit, afternoon nap, or cocktail hour is the source of the problem.

True enough. My pitch is always, 'look, if you were sleeping fine and you were watching TV for hours before bed, I would say go for it, clearly not a problem. But since whatever you are doing now is clearly not working, I figure if there's something that could be making it even a little harder, might make sense to skip it and see what happens for a week or two.'

Of course, I often end up going right to sleep restriction, which most people reluctantly agree to try. Most of the time when they actually do it it works and I look like a wizard. About ten percent of the time people say they do it 'and it didn't work', but funnily enough they can't supply any details of what they attempted to do or the way in which it didn't work. And I'd say twenty percent of the time people don't really implement it at all and still have the same complaint, so I go all excruciatingly detailed DBT BCA style in figuring out precisely what prevented them from doing it and eventually they do try it to make me shut up.