Psychiatry therapy in Family Medicine

[Howard7]

So I was looking at the CPT codes for psychology and psychiatry. There are CPT codes for psychotherapy and treatment.

Since family physicians treat depression, bipolar etc via medications and with counseling, can Family physicians use cpt code for psychotherapy and treatment for patients with depression?

Also, since psychiatrists are considered "specialtists". Is there a higher reimbursement CPT code if the treatment was done by a psychiatrist?

Similarly if a family physician is trained and receives hospital priviliges to do colonoscopy. Are family physicians reimbursed for the same colonoscopy as a gastroenterologist? Or are gastroenterologists reimbursed higher since they were "consulted".

Thank you very much for your help everyone.

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[deleted87716]

can Family physicians use cpt code for psychotherapy and treatment for patients with depression?

It depends on your contract with the insurance company. You'll have to ask them.

Some insurers won't pay for any mental health codes (like 311 or 300.02). Fortunately, this is getting less common.

Most of us simply bill based on time when we're spending a lot of time simply talking to patients. I've never billed a therapy code.

Is there a higher reimbursement CPT code if the treatment was done by a psychiatrist?

They could theoretically negotiate a better fee schedule, or you could. It's completely up to the insurer and how badly they need certain specialties in their network. With Medicare, it's the same fee for everybody.

Are family physicians reimbursed for the same colonoscopy as a gastroenterologist? Or are gastroenterologists reimbursed higher since they were "consulted".

It doesn't have anything to do with being "consulted." As above, Medicare fees are the same for everybody, regardless of specialty. Private insurers may negotiate different fee schedules with different specialties, or different doctors/groups within the same specialty. It's highly variable.

A specialist can bill a consult for the initial office visit for a patient properly referred to them for a consult. This is a one-time charge for any given problem. Additional visits after that are billed using the codes for established patient follow-up. Procedures are billed separately.

 

[Howard7]

Thanks bluedog. Follow up question. If you have a person geriatric or sports medicine fellowship in your group can the geriatric or sports medicine guy bill as a specialist. Also I noticed that there are ER fellowships. Does this mean they can bill and or hired as an ER physician. PEOPLE SAY THAT IT IS TOUGH TO BREAK INTO ER IN URBAN AREAS I WONDER IF THE ER FELLOWSHIP CAN OPEN DOORS TO CITIES. I have an interest in er but realize when i am 50 i dont waNT TO DO er but rather have a calm predictable hours. plus er fm fellowships are not too appealing to me.

 

[deleted87716]

If you have a person geriatric or sports medicine fellowship in your group can the geriatric or sports medicine guy bill as a specialist.

There's really no such thing as "billing as a specialist." You get paid according to your negotiated fee schedules with payers.

I noticed that there are ER fellowships. Does this mean they can bill and or hired as an ER physician.

Again, there's no such thing as "billing as an ER physician." Most ER docs are salaried, anyway.

Most hospitals aren't going to settle for non-BC/BE EM physicians unless they have trouble getting them. That's the reason most EM opportunities for non-EM docs are in rural or suburban locales. Supply and demand.

 

[lowbudget]

If you have a person geriatric or sports medicine fellowship in your group can the geriatric or sports medicine guy bill as a specialist.

Depends on the insurance company and/or plan and it also depends on how you negotiate your rates. You can list either under your primary specialty or under your secondary specialty. For some insurance plans, if you want to list under your secondary specialty, your rates may be higher, but patients may need a referral to see you. Some may require a prior authorization. But you could charge a higher copay. Unfortunately, during the time you are billing under your secondary specialty, the insurance company may restrict you from coding certain (procedure/diagnostic codes).

If you list under your primary specialty, you charge a primary copay and may have easier access to patients, but your rates may be lower. That being said, if people refer patients to you, you could code consult codes so long as you meet requirements (per above... until they take consult codes away).

If you want to do both, it can get confusing for patients if they have to pay a higher copay on one day and a lower copay on another day. While it's doable to be both a PCP and a specialist, some people choose to be one or the other just so patients (and payers) aren't confused.

 

[michaelrack]

So I was looking at the CPT codes for psychology and psychiatry. There are CPT codes for psychotherapy and treatment.

Since family physicians treat depression, bipolar etc via medications and with counseling, can Family physicians use cpt code for psychotherapy and treatment for patients with depression?

.

Theoretically yes. Practically speaking, no. Many insurance companies have mental health carve outs, and if you wanted to bill the psychotherapy codes you would need to be credentialled with the carve out plan, and not just the general medical plan.

 

[hkusp]

In regards to the psychotherapy CPT codes you would need to be credentialed and licensed to provide therapy. If you are not properly licensed to do so then you could be "accused" of practicing without licensure. For instance, I am a psychologist so I am credentialed to provide therapy. Much of the time, I am also reviewing the medication adherence, side effects, and fielding questions about what benzos are, why antidepressant can zap your love life, etc., etc. This could be seen as an opportunity to "bill" for psychiatric med checks. But, I am not credentialed or licensed to do so. I do VERY basic checks and often report my information to the psychiatrist/NP who is credentialed to do so. Since I see the patient most often I usually am the one that knows if they are Rx compliant. The psychiatrist is the expert in Rx so I obviously stay in my own lane in regards to legal requirements. They (most) don't do therapy and I don't do Rx. We work together because we need each other's expertise.

Providing psychotropic medications for bipolar would normally be within the realm of the psychiatrist's expertise as a general PC provider should not be expected to work with "Bipolar folks." They are often more than what a normal PC provider can address. It just isn't their area of expertise and they shouldn't be expected to provide the services. Providing therapy is not just about talking to a Patient about their MH symptoms. I just wish it were that simple! It is about much much more than just chatting with them about symptomology.

 

[benjee]

Theoretically yes. Practically speaking, no. Many insurance companies have mental health carve outs, and if you wanted to bill the psychotherapy codes you would need to be credentialled with the carve out plan, and not just the general medical plan.

by any chance, can you elaborate more on steps in getting credentialled (thru hospital ), negotiate with Insurance companies ,malpractice insurance.? which one need to be done first ??

 

[futureapppsy2]

by any chance, can you elaborate more on steps in getting credentialled (thru hospital ), negotiate with Insurance companies ,malpractice insurance.? which one need to be done first ??

Do a psychiatry residency, psychology PhD/PsyD, or Counseling/SW/MFT Masters...

Psychotherapy is a trained skill, one not taught in med school/non-psych residencies.

 

[chartero]

A Canadian resource, with training and networking opportunities perhaps also useful outside Canada, is the General Practice Psychotherapy Association. From its Training page:

Family physicians in Canada provide over half of the country's mental health care. While all family physicians received some training in medical psychotherapy in medical school, depending on the amount of psychological distress and mental illness presenting in their individual practice, that basic training may be insufficient to meet the needs of their practice.

The association offers a GP Psychotherapy Basic Skills Core Curriculum of seven weekend sessions in rural Ontario plus a final session associated with the GPPA conference, and an upcoming Training Program for Supervisors of GP Psychotherapy part-time over eighteen months.

futureapppsy2 has some great suggestions! I can't necessarily agree with their subsequent statement. Physicians are also eligible for AAMFT COAFMTE-accredited post-degree clinical training programs in Marriage and Family Therapy, a third pathway to MFT besides a master's or doctorate in MFT per se. Distinct but related: Drexel University offers an online Post Master’s Certificate in Medical Family Therapy; physicians and medical students are among eligible candidates. There are a good number of electives available; students might want to take extra.

 

[hkusp]

Do a psychiatry residency, psychology PhD/PsyD, or Counseling/SW/MFT Masters...

Psychotherapy is a trained skill, one not taught in med school/non-psych residencies.

I agree that therapy is a specialized skill that is not taught in medical school - how can it be when they are already drinking from a firehose. If what you mean by "psych" is psychology, then that statement isn't always true. If you meant "psych" as in psychiatrist, basic supportive counseling is taught in some psychiatric residencies. A good portion of the old school psychiatrists do some therapy, although they have had additional training to do so.

I did my psychological residency at a medical school and we helped teach the psychiatric residents some basic counseling skills and they helped us with their Rx expertise. They also shadowed some psychologists and were taught some basic things like the general CBT model and a little psychodynamic information like defense mechanisms. The psychiatric residency's goal was to teach them how to do general supportive therapy like developing their listening skills and the basic understanding of being a change agent. They were not taught the "therapeutic" therapy (as odd as that "therapeutic" bit sounds) as their focus was obviously on the biological bases of behavior.

Anyone who thinks "talk therapy" is just about talking is like equating the highly developed critical thinking skills of most medical doctors to just simply following algorithms.

 

[Abacab]

I agree that therapy is a specialized skill that is not taught in medical school - how can it be when they are already drinking from a firehose. If what you mean by "psych" is psychology, then that statement isn't always true. If you meant "psych" as in psychiatrist, basic supportive counseling is taught in some psychiatric residencies. A good portion of the old school psychiatrists do some therapy, although they have had additional training to do so.

I did my psychological residency at a medical school and we helped teach the psychiatric residents some basic counseling skills and they helped us with their Rx expertise. They also shadowed some psychologists and were taught some basic things like the general CBT model and a little psychodynamic information like defense mechanisms. The psychiatric residency's goal was to teach them how to do general supportive therapy like developing their listening skills and the basic understanding of being a change agent. They were not taught the "therapeutic" therapy (as odd as that "therapeutic" bit sounds) as their focus was obviously on the biological bases of behavior.

Anyone who thinks "talk therapy" is just about talking is like equating the highly developed critical thinking skills of most medical doctors to just simply following algorithms.

If that's the case, it must have been a sub-par residency program. I don't know which program you are referring to, but virtually all psych residencies are required to teach how to use (not just a basic understanding) all major modalities of psychotherapy in addition to supportive. It is an accreditation requirement.

Psychiatrists still can, and do, perform therapy. It is well integrated into the curriculum of my residency program as well as many others.

I think there is some confusion because many psychiatrists end up using this skill sparingly, if at all, while in practice. However, this is not due to ineptitude.

There are many things psychologists learn during their training that we physicians do not. However, there are plenty of psychiatrists are are excellent at psychotherapy. There are those who are terrible at it as well, but the same can be said about psychologists...or any mental health professional.

 

[hkusp]

If that's the case, it must have been a sub-par residency program. I don't know which program you are referring to, but virtually all psych residencies are required to teach how to use (not just a basic understanding) all major modalities of psychotherapy in addition to supportive. It is an accreditation requirement.

Psychiatrists still can, and do, perform therapy. It is well integrated into the curriculum of my residency program as well as many others.

I think there is some confusion because many psychiatrists end up using this skill sparingly, if at all, while in practice. However, this is not due to ineptitude.

There are many things psychologists learn during their training that we physicians do not. However, there are plenty of psychiatrists are are excellent at psychotherapy. There are those who are terrible at it as well, but the same can be said about psychologists...or any mental health professional.

Yes, I agree with you regarding the statement that psychiatrists can be especially adept at therapy. I know one in particular who loved therapy and was always wanting to learn more. I learned a significant amount from the psychiatric attendings that were mentors. The residency program I attended was at a well known medical school. I will acknowledge that my view is limited in that most of the psychiatric residents I trained with were not as interested in learning therapy. Many of the residents were there as this particular medical school was well known for its work with Patients with schizophrenia.

Yes, there are certainly psychologist who are terrible at therapy and no little to nothing about the biological bases of behavior.

This response was not meant to fuel any interdisciplinary rivalary or rehash the whole "but, but, I'm better." We certainly have enough of that in MH.

 

[MedicineDoc]

I for one as a generalist physician will treat whatever I feel comfortable with. I mostly refer to psychologist people who don't appear to be able to think through their problems or very dysfunctional people who mostly won't go even if I refer and those that seem like they just need someone supportive to talk to for longer than I can. People will always try to carve out some turf but affordable healthcare starts with a generalist treating what he is capable of treating which increases every year he is in practice.

 

[futureapppsy2]

I meant psych residency as in psychiatry. There aren't residencies in clinical psychology--there are internships and post-docs.

 

[lowbudget]

I for one as a generalist physician will treat whatever I feel comfortable with. I mostly refer to psychologist people who don't appear to be able to think through their problems or very dysfunctional people who mostly won't go even if I refer and those that seem like they just need someone supportive to talk to for longer than I can. People will always try to carve out some turf but affordable healthcare starts with a generalist treating what he is capable of treating which increases every year he is in practice.

Agreed.

Psych care in the US is a total joke. People like to carve out turfs and pound their chest about how specialized and great they are, but the reality is patients have an incredibly hard time getting in to see their psychiatrist, psychologist, and counselors when they're needed. Most community hospitals in the US don't have psych floors anymore, and psych hospitals are always packed/closing. If I had a quarter for every time I can't get a patient to get the proper mental health care they need, my student loans would be paid off.

So, while the academic types are sitting around the table clusterf*cking over who should be doing what to whom because some training they got, the reality is they are wasting their breath talking about how great they are instead of talking to and listening to patients who need them. You can't get a patient to see these mental health people. The reality is the majority of the care rests on the shoulder of primary care physicians who receive almost to no communication or help from mental health specialists. As hard as it is to get in to see your PCP, it's even harder to see your mental health provider.

Part of it is that the public does not value mental health, which is one reason why reimbursement for mental health keep falling, salaries keep falling, hospitals and providers keep contracting. The other part is the mental health lobby has such a weak political lobby.

But, in large part, mental health as a field, whether you're talking about psychiatry, psychology, and counseling is so voodoo, and such a cesspool of research, discovery, and scientific inquiry that nobody (insurance, patients, government) want to pay for it. Or pay up for it. As exciting as the molecular and biological basis of behavior has been in the last 20-30 years, cognitive research has been a total and utter joke. Who the hell wants to pay for some who sells a bunch of snake oil talk therapy? Why do you think psychiatrists don't do counseling anymore? Not because they aren't qualified to do it, but because it's a waste of their time in dollar terms. Why do we have mental health carve out in commercial insurance policies? Is it not viewed as a medical problem? Is it because mental health providers (like these quack psychoanalysts in the past) milked the system and now we're all paying for their greed?

And don't try to convince me that counseling is best delivered by a PhD in psychology, because we all know that the vast majority of counseling services offloaded onto people with Masters in Social Work, or Masters in Education, or some other masters-level education with a license to provide counseling. Counseling and psychotherapy doesn't pay worth crap; and that's why as a society, we ask those who get paid $40-60k to do it for us, instead of the $90k psychologist or the $180k psychiatrist.

All of us in primary care know how valuable counseling and psychologists and psychiatrists are. We definitely could use more help down here in the "trenches". But if you refuse my patient because they don't have insurance, don't have the 1 or 2 insurances that you carry, you damn right I'm gonna come and do your job and take your money. Not because I should or that I'm the "most" qualified, but because my patients and I have no choice. And trust me, I will start with the uninsured and underprivileged. And my next stop will be your paying patients.

For those of you doing mental health, get your act together and get a seat at the table on health care reform. I'm tired of doing your work for you.

 

[futureapppsy2]

But, in large part, mental health as a field, whether you're talking about psychiatry, psychology, and counseling is so voodoo, and such a cesspool of research, discovery, and scientific inquiry that nobody (insurance, patients, government) want to pay for it. Or pay up for it. As exciting as the molecular and biological basis of behavior has been in the last 20-30 years, cognitive research has been a total and utter joke. Who the hell wants to pay for some who sells a bunch of snake oil talk therapy? Why do you think psychiatrists don't do counseling anymore? Not because they aren't qualified to do it, but because it's a waste of their time in dollar terms. Why do we have mental health carve out in commercial insurance policies? Is it not viewed as a medical problem? Is it because mental health providers (like these quack psychoanalysts in the past) milked the system and now we're all paying for their greed?

Wow, that's a whole lot of ignorance in one paragraph.

 

[lowbudget]

Wow, that's a whole lot of ignorance in one paragraph.

Enlighten me, then...

 

[futureapppsy2]

Enlighten me, then...

Tons of government funding goes until psychological/psychotherapy research. For example, in the three years since she's been here, my PI alone has brought in almost $2.8 million in federal (CDC/NIDDR/NIH [I think]) funding for psychosocial health research. Also, there are tone of studies showing good psychotherapeutic outcomes/health outcomes, some even using imaging (MRI/fMRI/CT) to show significant changes in neurological function as a result of psychotherapy, if that'd be more conveincing to you. To say psychotherapy is all "snake oil" (sure, there is "quack" therapy, just like there is "quack medicine) is to ignore a huge body of research. Finally, there is still very much a demand for/need for therapy among a lot of people, mostly because it has been shown to significant improve outcomes in many situations/disorders, sometimes even at higher rate than psychopharm interventions.

 

[hkusp]

Agreed.

Psych care in the US is a total joke. People like to carve out turfs and pound their chest about how specialized and great they are, but the reality is patients have an incredibly hard time getting in to see their psychiatrist, psychologist, and counselors when they're needed. Most community hospitals in the US don't have psych floors anymore, and psych hospitals are always packed/closing. If I had a quarter for every time I can't get a patient to get the proper mental health care they need, my student loans would be paid off.

So, while the academic types are sitting around the table clusterf*cking over who should be doing what to whom because some training they got, the reality is they are wasting their breath talking about how great they are instead of talking to and listening to patients who need them. You can't get a patient to see these mental health people. The reality is the majority of the care rests on the shoulder of primary care physicians who receive almost to no communication or help from mental health specialists. As hard as it is to get in to see your PCP, it's even harder to see your mental health provider.

Part of it is that the public does not value mental health, which is one reason why reimbursement for mental health keep falling, salaries keep falling, hospitals and providers keep contracting. The other part is the mental health lobby has such a weak political lobby.

But, in large part, mental health as a field, whether you're talking about psychiatry, psychology, and counseling is so voodoo, and such a cesspool of research, discovery, and scientific inquiry that nobody (insurance, patients, government) want to pay for it. Or pay up for it. As exciting as the molecular and biological basis of behavior has been in the last 20-30 years, cognitive research has been a total and utter joke. Who the hell wants to pay for some who sells a bunch of snake oil talk therapy? Why do you think psychiatrists don't do counseling anymore? Not because they aren't qualified to do it, but because it's a waste of their time in dollar terms. Why do we have mental health carve out in commercial insurance policies? Is it not viewed as a medical problem? Is it because mental health providers (like these quack psychoanalysts in the past) milked the system and now we're all paying for their greed?

And don't try to convince me that counseling is best delivered by a PhD in psychology, because we all know that the vast majority of counseling services offloaded onto people with Masters in Social Work, or Masters in Education, or some other masters-level education with a license to provide counseling. Counseling and psychotherapy doesn't pay worth crap; and that's why as a society, we ask those who get paid $40-60k to do it for us, instead of the $90k psychologist or the $180k psychiatrist.

All of us in primary care know how valuable counseling and psychologists and psychiatrists are. We definitely could use more help down here in the "trenches". But if you refuse my patient because they don't have insurance, don't have the 1 or 2 insurances that you carry, you damn right I'm gonna come and do your job and take your money. Not because I should or that I'm the "most" qualified, but because my patients and I have no choice. And trust me, I will start with the uninsured and underprivileged. And my next stop will be your paying patients.

For those of you doing mental health, get your act together and get a seat at the table on health care reform. I'm tired of doing your work for you.

You know, I actually agree with most of what you wrote and I am a psychologist. Minus the statements not based on scientific research of course. Both psychiatry and psychology show very good results, both from neurobiological standards and behavioral standards. Once patients get over their fear of being labeled "crazy" they sing our (really their own) praises.

Mental health people really are pretty bad at communicating with primary care, and often with other specialities as well. We tend to enjoy our intellectual banter, at times to the detriment of other more important priorities. The problem with psychology is that half of our PhDs go to research and about half go to clinical work. There are only about 3000 PhDs that graduate every year so our numbers are pretty small.

Back to your point, when MH and PC work together it is a beautiful thing. I spent a year working in a primary care clinic at a VA hospital and both the MDs and PhDs could introduce patients to one another, talk about cases, etc. However, there was only one full time psychology attending that received about 60 new referrals (from the 3 PCPs) each month.

Psychology really has fallen down on the job in integrating care with those of you on the front lines of medicine. It seems a shame because there is so much we can learn from each other. So many "health" issues are psychogenic and oftentimes, we need your help in understanding the multiple medical issues that are presented. I hate it that we are where we are in the sense that PCPs are having to work in areas in which they are not trained because they can't get their patient to a MH provider. Likewise, I find myself having to work with Rx questions, etc. because I can't find a psychiatrist with an opening for 3 months and the PCP isn't sure what to prescribe my very angry OEF vet with PTSD and TBI.

Overall, it sucks. And yes, MH does need to do a better job of displaying their skills to physicians and patients alike. We tend to be an insular nerdy group that gets excited over academic info rather than reaching out to other professions.

 

[Shikima]

FP can bill for "psychotherapy" time on CPT coding. There is no specific code for this. However, you can use the generic CPT coding and bill for "consultative time" in 15 minute increments.

However, You're going to lose more money than it is worth and the days off that you have, you will want to spend the time spending the money you earn.

I hope this helps. Btw, this information was given to me by 2 well established FP doctors and they do this routinely.

 

[deleted87716]

FP can bill for "psychotherapy" time on CPT coding. There is no specific code for this. However, you can use the generic CPT coding and bill for "consultative time" in 15 minute increments.

You can bill based on time whenever you spend more than 50% of the visit counseling on any subject, not just "psychotherapy." It's not technically in 15 min. increments, however...it goes 10, 15, 25, and 40 minutes for a 99212, 99213, 99214, and 99215 respectively (established outpatient visit codes). Your note must contain a brief summary of the content of the counseling.

 

[Shikima]

Correct Blue Dog. My statement was more answering the question of how can FP bill for psychotherapy time. You use consultation codes as you described very well!!


But the question one should ask is, is it worth the time for the bottom line. Plenty of overhead in primary care. If money isn't a problem, gold spoons are plenty, then go for it. The rest of us will suffer in silence wondering how to make ends meet.