VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[texanpsychdoc]

Agreed.

Logic would suggest that it's either:

(a) a bona fide psychiatric emergency (SI/HI) or

(b) it's not.

In case (a), even if you see an outpatient provider, you're likely just going to the ER anyway to be admitted...could have gone there in the first place.

In case (b), it can wait until your next scheduled appointment.

This exact scenario happened to me last month - I received an email from our executive director of MH who copied my supervisor and some other folks on letting me know there was a veteran who was recently seen in the ER and is currently admitted. They indicated I had previously seen this veteran, and that there were multiple instances where a follow up appointment was scheduled but they no showed multiple times. I made sure to reinforce that sentiment but also told them of my 3 strike/no show/call in status policy, and that I don't chase down veterans. I advised them that it appears this veteran is exactly where they need to be (inpatient) to be stabilized secondary to alcohol detox, and that if still want to engage in outpatient services, they have my contact info and we can resume services. I didn't hear anything after that. My supervisor even emailed me told me he was in full support of my position and agreed.

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[texanpsychdoc]

Get this - at my VA, it's not good enough to put in three no show notes for each call you make on each day (3 calls across 3 days) - no, they also want you to add an addendum to the original no show note each time you make your no show call.

 

[Sanman]

Get this - at my VA, it's not good enough to put in three no show notes for each call you make on each day (3 calls across 3 days) - no, they also want you to add an addendum to the original no show note each time you make your no show call.

If only there was a person that the government could hire who could handle all of these complex notes required for no shows and maybe even make new appts for them. I wonder what that would be like.

 

[Fan_of_Meehl]

Get this - at my VA, it's not good enough to put in three no show notes for each call you make on each day (3 calls across 3 days) - no, they also want you to add an addendum to the original no show note each time you make your no show call.

Yeah...I worked at my VA for YEARS before anyone clarified the procedure they actually wanted me to follow documenting no show notes. I would repeatedly get bitched at, but no one showed me how to actually do it right.

What they want you to do is to select the initial no show note in CPRS and do 'child' notes (which look like addenda) for calls 2 and 3 by selecting 'Action' ---> 'Add New Entry to Interdisciplinary Note' and choose the 'CIN MH NO SHOW FOLLOW-UP NOTE.'

Of course, it is for the convenience of the 'gotcha' hatchetperson doing the no show followup 'tracer' reviews so that all the notes are in one neat bundle for them so they don't have to strain their pretty eyes scanning up to a 150mm radius cone up/down the screen whilst doing their reviews. Or maybe it would consume too much short-term memory buffer slots (up to 3) if they had to read a bundle of, say, 10 consecutive notes and pick out (and sum) up to three separate notes that have 'NO SHOW NOTE' in their titles. We wouldn"'t want to inconvenience a non-provider staff member under any circumstances. To be fair, it probably is also for the convenience of data collection at the national or VISN level, too, I suppose.

People kept bitching at me to make it look like that for years before anyone bothered to teach me HOW to actually do that in the chart. Go figure.

 

[AcronymAllergy]

Give me until 2023 and I can make that happen.



So, this was something I learned from my former chief at a previous VA. It was his own technique that he taught me, and it has worked wonders. alternatively, we have a same-day access team that addresses the issue of making sure veterans are seen same day, so that's how I can use my approach.

Also, I would disagree with the sentiment that this approach is a "withholding of care." An example of that would be just flat out telling them after 3 no shows, I won't see them anymore. That's not what's being done here. It's reinforcing personal responsibility on the veteran's end, and it ensures I am not working harder than they are in treatment.

Oh, I'm not saying I agree with their sentiment. But it seemed that their perception was anything that seems to put an obstacle or potential inconvenience in the way of a veteran seeking care could be seen as restricting access to care.

 

[texanpsychdoc]

Yeah...I worked at my VA for YEARS before anyone clarified the procedure they actually wanted me to follow documenting no show notes. I would repeatedly get bitched at, but no one showed me how to actually do it right.

What they want you to do is to select the initial no show note in CPRS and do 'child' notes (which look like addenda) for calls 2 and 3 by selecting 'Action' ---> 'Add New Entry to Interdisciplinary Note' and choose the 'CIN MH NO SHOW FOLLOW-UP NOTE.'

Of course, it is for the convenience of the 'gotcha' hatchetperson doing the no show followup 'tracer' reviews so that all the notes are in one neat bundle for them so they don't have to strain their pretty eyes scanning up to a 150mm radius cone up/down the screen whilst doing their reviews. Or maybe it would consume too much short-term memory buffer slots (up to 3) if they had to read a bundle of, say, 10 consecutive notes and pick out (and sum) up to three separate notes that have 'NO SHOW NOTE' in their titles. We wouldn"'t want to inconvenience a non-provider staff member under any circumstances. To be fair, it probably is also for the convenience of data collection at the national or VISN level, too, I suppose.

People kept bitching at me to make it look like that for years before anyone bothered to teach me HOW to actually do that in the chart. Go figure.

I just love how you stated this. I was laughing pretty hard. This is exactly how I feel. Like, all of this admin stuff I do, I sit here and think "I wonder if we could hire someone to do all this non-patient-oriented work?" I would have thought MSAs would, but silly me. Should we create a whole new position to address these things?

The last two VAs I was at only required you to submit separate no show notes each time you called. That was it. Even in the VA I am at now, when you select the MH No Show note template, it prompts you to select "1st, 2nd, or 3rd" time you attempted to contact them. You would think that's pretty straight forward right? Nope. Evidently not.

 

[texanpsychdoc]

Oh, I'm not saying I agree with their sentiment. But it seemed that their perception was anything that seems to put an obstacle or potential inconvenience in the way of a veteran seeking care could be seen as restricting access to care.

Gotcha - yeah, it's so interesting that despite the VA being one entity, there is no unified approach in addressing things like no shows, scheduling, etc. Each VA seems to have their own unique SOP on the matter.

 

[Fan_of_Meehl]

I just love how you stated this. I was laughing pretty hard. This is exactly how I feel. Like, all of this admin stuff I do, I sit here and think "I wonder if we could hire someone to do all this non-patient-oriented work?" I would have thought MSAs would, but silly me. Should we create a whole new position to address these things?

The last two VAs I was at only required you to submit separate no show notes each time you called. That was it. Even in the VA I am at now, when you select the MH No Show note template, it prompts you to select "1st, 2nd, or 3rd" time you attempted to contact them. You would think that's pretty straight forward right? Nope. Evidently not.

At some remote VISN some 'Measurement-Based Care / Evidence-Based Documentation Paladin/Champion/Manager levels 12/8/10 multiclassed guru probably got a Nobel Prize for Bureaucracy for the innovative design of that particular CPRS template. Guaranteed.

 

[cara susanna]

Yeah, with the impending snowstorm we're being asked to call our intakes and ask them if they want virtual. Keep in mind these are patients we've never met before. Why can't the MSAs do that?

 

[Fan_of_Meehl]

Yeah, with the impending snowstorm we're being asked to call our intakes and ask them if they want virtual. Keep in mind these are patients we've never met before. Why can't the MSAs do that?

This is borderline provider abuse.

 

[Sanman]

Yeah, with the impending snowstorm we're being asked to call our intakes and ask them if they want virtual. Keep in mind these are patients we've never met before. Why can't the MSAs do that?

This is the one thing I am willing to do simply because I don't plan on leaving home.

As to why MSAs can't do that, finger sprain from all that dialing?

 

[AbnormalPsych]

Yeah, with the impending snowstorm we're being asked to call our intakes and ask them if they want virtual. Keep in mind these are patients we've never met before.

What in the world.

 

[Fan_of_Meehl]

What in the world.

It's a wonder they're not mandated to offer them a welfare/safety check, a red white and green Christmas-themed pacifier (with '#WEREALLINTHISTOGETHER' emblazoned on the mouth shield), and a team of Siberian huskies.

 

[texanpsychdoc]

It's a wonder they're not mandated to offer them a welfare/safety check, a red white and green Christmas-themed pacifier (with '#WEREALLINTHISTOGETHER' emblazoned on the mouth shield), and a team of Siberian huskies.

So...my husky is at home with me. I work 3 days out of the week from home, and he is a handful. There have been some times he and my our other dog are running up and down the stairs and my patients can hear them.

 

[Sanman]

It's a wonder they're not mandated to offer them a welfare/safety check, a red white and green Christmas-themed pacifier (with '#WEREALLINTHISTOGETHER' emblazoned on the mouth shield), and a team of Siberian huskies.

You joke, but I just got an email about cold calling with our older folks to do welfare checks given the weather. Granted, they are by phone and not in person. Not out of the realm of possibility. Let me know when the pacifiers come in.

 

[Shiori]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

 

[texanpsychdoc]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

This summarizes circa 2019-present.

 

[ccpsych16]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

I see a lot of “PD unspecified”, especially from prescribers. But like you said, not often accompanying a rationale. Or if there are symptoms listed, they aren’t any that I’ve personally observed as someone who spends much more time with them than a prescriber.

 

[allantois]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

For all the DSM efforts, I often find diagnoses from other clinicians next to useless especially since so many insist on using their own criteria/astrology for diagnosing patients

 

[cara susanna]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

Yup. Woman who experienced MST? You'd better believe there's probably gonna be BPD on the problems list.

I'm annoyed because I had a cancelled intake and the MSAs put in a high risk person into the open slot THE SAME DAY OF THE APPOINTMENT. And now I have all of this suicide prevention admin stuff I'm gonna have to do during the intake. Arghhh.

 

[cara susanna]

Oh man, any other PCT/PTSD people following the prolonged service code thing? The funny thing is people (myself included) raised the alarm before it happened and upper management wasn't concerned, like they didn't think it would impact us in the VA for some reason. Well, we tried!

 

[Fan_of_Meehl]

Oh man, any other PCT/PTSD people following the prolonged service code thing? The funny thing is people (myself included) raised the alarm before it happened and upper management wasn't concerned, like they didn't think it would impact us in the VA for some reason. Well, we tried!

Did they change the rvu's or something?

 

[futureapppsy2]

BPD and ASPD seem to be given to a lot of people who are just irritating to work with. If the providers have a stronger rationale, they definitely don't document it well. So many paragraphs are written about how the person wasn't nice to them or they were non-adherent, but they don't hit on any of the basic symptoms for diagnosis. I'm ranting because someone made my job harder today. I need facts, not feelings. At least give me both.

Some professionals use "personality disorder" as a synonym for "client I don't like."

 

[cara susanna]

Did they change the rvu's or something?

They got rid of it entirely, so now you can only bill PE and other 90 min appts as the 60 min code. So, yes, people are freaking out about RVUs (the hilarious thing is this wouldn't be a big deal if productivity weren't measured by appt length).

 

[Sanman]

They got rid of it entirely, so now you can only bill PE and other 90 min appts as the 60 min code. So, yes, people are freaking out about RVUs (the hilarious thing is this wouldn't be a big deal if productivity weren't measured by appt length).

Thanks for sharing. This is the first I am hearing of this. APA still doesn't have anything out for 2023 CPT code changes that I have seen.

 

[Fan_of_Meehl]

They got rid of it entirely, so now you can only bill PE and other 90 min appts as the 60 min code. So, yes, people are freaking out about RVUs (the hilarious thing is this wouldn't be a big deal if productivity weren't measured by appt length).

Great. I just learned a 2 hour per session CBT for Nightmares ERRT protocol. LOL.

Maybe I'll ad lib in a little 10 minute 'intermission' in between my two 60 min half-sessions. Bastards.

 

[Fan_of_Meehl]

They got rid of it entirely, so now you can only bill PE and other 90 min appts as the 60 min code. So, yes, people are freaking out about RVUs (the hilarious thing is this wouldn't be a big deal if productivity weren't measured by appt length).

Yeah. And the real kick in the pants is that RVU's were never (originally) INTENDED to MEASURE PRODUCTIVITY of individual providers. It even said so explicitly in the original language (basically, a disclaimer not to use it as some index of productivity).

 

[deleted1038433]

Working for the VA sucks sometimes/often/everyday. Tell me about your successful escapes to private practice.

 

[erg923]

Working for the VA sucks sometimes/often/everyday. Tell me about your successful escapes to private practice.

Seeing patients followed by seeing even more patients.... is probably not a booster...even if making more money on that flip side. Maybe an MBA and/or working with health care administration?

 

[WisNeuro]

Working for the VA sucks sometimes/often/everyday. Tell me about your successful escapes to private practice.

Make your own schedule, make multiples of your old salary, do only the work you want/choose to do. What's not to like?

 

[Sanman]

Working for the VA sucks sometimes/often/everyday. Tell me about your successful escapes to private practice.

There are many ways to leave the VA that you can hear about. The question is what can you tolerate at this point in your life. Can you afford to go without a biweekly paycheck? Are you a big fan of paid time off or like to work?

Said another way...do you want to be an employee or start a business?

 

[IWillSurvive]

They got rid of it entirely, so now you can only bill PE and other 90 min appts as the 60 min code. So, yes, people are freaking out about RVUs (the hilarious thing is this wouldn't be a big deal if productivity weren't measured by appt length).

As a follow-up to this, we are being told basically to not use 90837, only in extenuating circumstances and if you do use it, prepare to be audited and make sure you document what made the session go beyond 52 minutes specifically. Before some pushback, the suggestion was if your session lasts 55 minutes, still only code it as 90834. I mean...why? Anyone else hearing this?

 

[Fan_of_Meehl]

As a follow-up to this, we are being told basically to not use 90837, only in extenuating circumstances and if you do use it, prepare to be audited and make sure you document what made the session go beyond 52 minutes specifically. Before some pushback, the suggestion was if your session lasts 55 minutes, still only code it as 90834. I mean...why? Anyone else hearing this?

And they keep adding SH^^ that you have to squeeze into every encounter (clinical reminders, measures, MH Suite 'treatment planning', etc.). It's like they want people to quit.

 

[cara susanna]

As a follow-up to this, we are being told basically to not use 90837, only in extenuating circumstances and if you do use it, prepare to be audited and make sure you document what made the session go beyond 52 minutes specifically. Before some pushback, the suggestion was if your session lasts 55 minutes, still only code it as 90834. I mean...why? Anyone else hearing this?

I was told this before, but given feedback in this thread that we don't have to document why a session went beyond 52 min. Has that changed?

I always want to write something like "patient wouldn't shut up"

 

[Fan_of_Meehl]

I was told this before, but given feedback in this thread that we don't have to document why a session went beyond 52 min. Has that changed?

I always want to write something like "patient wouldn't shut up"

I mean...it's not like the standard psychotherapy session length has been established for, oh, for greater than a century to be just shy of an hour, or anything. So, let me get this straight...any session length >45 mins is now to be considered some sort of 'prolonged service' type situation requiring specific defensive documentation on the part of the provider 'justifying' that length?

Being a VA mental health provider these days is requiring pathological levels of clinical masochism. At this point, they should list this as a job requirement in position descriptions.

 

[WisNeuro]

I mean...it's not like the standard psychotherapy session length has been established for, oh, for greater than a century to be just shy of an hour, or anything. So, let me get this straight...any session length >45 mins is now to be considered some sort of 'prolonged service' type situation requiring specific defensive documentation on the part of the provider 'justifying' that length?

Being a VA mental health provider these days is requiring pathological levels of clinical masochism. At this point, they should list this as a job requirement in position descriptions.

Is the VA just fully abandoning PE as a PTSD tx now?

 

[Fan_of_Meehl]

Is the VA just fully abandoning PE as a PTSD tx now?

Lack of internal consistency is the sine qua non of VA bureaucracy.

The principle of non-self-contradiction eludes them all.

 

[Sanman]

As a follow-up to this, we are being told basically to not use 90837, only in extenuating circumstances and if you do use it, prepare to be audited and make sure you document what made the session go beyond 52 minutes specifically. Before some pushback, the suggestion was if your session lasts 55 minutes, still only code it as 90834. I mean...why? Anyone else hearing this?

Yeah, that's billing fraud. Tell them to put that in a written memo for you and then report it.

As for the rest, that is essentially how it has been with insurance based therapy. Not sure what the reasoning behind this is at the VA.

 

[texanpsychdoc]

As a follow-up to this, we are being told basically to not use 90837, only in extenuating circumstances and if you do use it, prepare to be audited and make sure you document what made the session go beyond 52 minutes specifically. Before some pushback, the suggestion was if your session lasts 55 minutes, still only code it as 90834. I mean...why? Anyone else hearing this?

Should be a 90837 which ranges 53-60 minutes.

 

[cara susanna]

I'm definitely not going to stop using 90837. I am VERY conservative about coding, perhaps too much, so I use that code sparingly and if I do it is for a good reason. If they want to audit me, bring it on I guess.

 

[Sanman]

I'm definitely not going to stop using 90837. I am VERY conservative about coding, perhaps too much, so I use that code sparingly and if I do it is for a good reason. If they want to audit me, bring it on I guess.

Not sure what the consequences would be of a VA billing audit? It is not a goal for the standard performance evaluation. They can claw back money from the hospital, but I don't care about that.

 

[IWillSurvive]

I'm definitely not going to stop using 90837. I am VERY conservative about coding, perhaps too much, so I use that code sparingly and if I do it is for a good reason. If they want to audit me, bring it on I guess.

This is me exactly. I rarely use it and I want credit for it when I do!

Glad we had this chat, everyone.

 

[texanpsychdoc]

I typically cap my therapy sessions at 45 minutes so 99% of the time I am using the 90834. Very rarely will I use the 90832 or 90837. I use 90791 at least 4 times or more a week since I do a lot of intake evaluations plus my testing cases, in which I will also be throwing in some testing codes.

 

[ccpsych16]

If we’re not meant to use 90837 often, they should be reducing RVU expectations. There’s already been discussions amongst leadership (based on feedback from us providers) that book ability expectations are too much to manage with all the other extra admin stuff and clinical reminders they’re wanting us to do “on time”. Hopefully we see some changes locally. Haven’t heard any guidance about not using 90837 locally.

 

[Fan_of_Meehl]

If we’re not meant to use 90837 often, they should be reducing RVU expectations. There’s already been discussions amongst leadership (based on feedback from us providers) that book ability expectations are too much to manage with all the other extra admin stuff and clinical reminders they’re wanting us to do “on time”. Hopefully we see some changes locally. Haven’t heard any guidance about not using 90837 locally.

Any speculation on possible *motivation* for admin to--off the record--dissuade providers from coding 53 min+ sessions (and earning 3 rvus /encounter vs 2 or 1?). Why would they be trying to lower 'productivity' stats? Also, there has been nothing (yet) said about this at my site. Are they concerned about the casual abuse of the 60min code by providers actually doing briefer sessions but fraudulently up-coding sessions or something?

 

[WisNeuro]

Any speculation on possible *motivation* for admin to--off the record--dissuade providers from coding 53 min+ sessions (and earning 3 rvus /encounter vs 2 or 1?). Why would they be trying to lower 'productivity' stats? Also, there has been nothing (yet) said about this at my site. Are they concerned about the casual abuse of the 60min code by providers actually doing briefer sessions but fraudulently up-coding sessions or something?

I wonder for the patients that they actually do try to bill for, they are getting audited routinely by insurers, like other healthcare systems in which providers use the longer codes. Insurers hate paying for those.

 

[Fan_of_Meehl]

I wonder for the patients that they actually do try to bill for, they are getting audited routinely by insurers, like other healthcare systems in which providers use the longer codes. Insurers hate paying for those.

I know, anecdotally, I have noticed some providers appearing to have a tendency to code EVERY or nearly every session using the 53+ min code even though they almost certainly haven't seen every patient for that long. Again, anecdotally, whenever I've probed a bit with questions, I'd get a response like, "Well, I mean, if I count the time I spent writing the notes and entering the measures then it adds up to 55 mins...[awkward silence]." Yeah, colleague, you do you but I'm not committing billimg fraud just to try to get a 'high score' on my 'productivity' metric.

What I find amazing (though maybe not) is that in all the years I've been here, we have never been inserviced or formally trained on billing/coding issues like this. Of all the nonsense we cover in service meetings, the important topics are rarely ever addressed.

 

[cara susanna]

I know, anecdotally, I have noticed some providers appearing to have a tendency to code EVERY or nearly every session using the 53+ min code even though they almost certainly haven't seen every patient for that long. Again, anecdotally, whenever I've probed a bit with questions, I'd get a response like, "Well, I mean, if I count the time I spent writing the notes and entering the measures then it adds up to 55 mins...[awkward silence]." Yeah, colleague, you do you but I'm not committing billimg fraud just to try to get a 'high score' on my 'productivity' metric.

What I find amazing (though maybe not) is that in all the years I've been here, we have never been inserviced or formally trained on billing/coding issues like this. Of all the nonsense we cover in service meetings, the important topics are rarely ever addressed.

Many providers I know use it a ton, but they also seem to actually meet with their patients that long (I also think that's why so many of them are swamped and have to do notes or other admin stuff outside of work).

I honestly think a lot of people overcode for PE sessions too. I don't often go the full 90 min.

 

[WisNeuro]

Many providers I know use it a ton, but they also seem to actually meet with their patients that long (I also think that's why so many of them are swamped and have to do notes or other admin stuff outside of work).

I honestly think a lot of people overcode for PE sessions too. I don't often go the full 90 min.

Full 90 minutes, maybe not, but I don't remember many sessions of PE that didn't go 60+, especially the early to mid sessions.

 

[cara susanna]

Full 90 minutes, maybe not, but I don't remember many sessions of PE that didn't go 60+, especially the early to mid sessions.

Yeah, mine usually go 60+, but technically the 90837 code is supposed to be up to 89 min so anything short of 90 min would fall under that.

I have started doing 60 min PE lately too, due to more flexibility with timeslots.