Wednesday, November 19, 2008

Is This It? Are We Talking Yet?

So a new patient presents with the usual chief complaint of: "I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully." Patent after patient, all day long.

In case you didn't catch my sarcasm, no one has EVER presented (to me) with such a request, perhaps because I'm not a psychoanalyst? People come because:

They are having psychiatric symptoms such as sustained sadness, irritability, panic attacks, anxiety... fill in the blank ....

Bad things are happening in their lives and they are having trouble coping.

So Roy has been talking about CPT coding-- the codes psychiatrists submit to insurance companies that explain what we do to get reimbursed-- and about new Diagnostic Criteria in the making. We talked about CPT coding on our soon-to-be released My Three Shrinks Podcast, and it got me thinking:

What makes it Psychotherapy? Roy pointed out that there is felt to be a problem with the CPT code 90862-- Medication Management, a code unique to psychiatry. The reimbursement is the same if you spend 5 minutes or 500 minutes with the patient managing their medications, there are no gradations, and clearly the slant is to pay docs more to see more patients for less time each. You can call it psychotherapy, and then time figures in-- there are codes for 25 minute therapy sessions and 50 minutes therapy sessions, but it all got me thinking.

So like what does make it psychotherapy? If a patient walks in the door for a session that is scheduled as a medication management session and the doctor asks, "How are you?" and the patient starts talking about a stressful circumstance they are dealing with in their lives and feels helped by the brief session: is that psychotherapy? How long does the session have to last? How regularly does it have to occur? Many people want sessions every other week or once a month because they can't afford weekly, or twice weekly, sessions or they can't logistically make the time in their lives. Other people don't even want to schedule that regularly, they call when they want to come in and the frequency of sessions varies with how they are doing. Even with irregular sessions, many people do really good work and make really substantial changes in how they deal with the world or how they let the world deal with them, and they find the sessions helpful, but it may not be an on-going process.

So what does make it therapy? The Psychiatric Times front page article this week is called The Decline of Psychotherapy-- it takes info from
National Trends in Psychotherapy by Office-Based Psychiatrists
Mojtabai and Olfson
Arch Gen Psychiatry.2008; 65: 962-970.
and it goes into statistics on how many (or how few) psychiatrists do therapy with all or some of their patients, all or some of the time, now versus way back when.

Psychotherapy is a treatment where the talking is part of the cure. From the best I can figure, if the psychiatrist calls it therapy, and the patient calls it therapy, then whatever transpires between the two is therapy, and hopefully someone finds it helpful.


Rach said...

From the best I can figure, if the psychiatrist calls it therapy, and the patient calls it therapy, then whatever transpires between the two is therapy, and hopefully someone finds it helpful.

Ahh yes, I totally agree.
Dinah, was it you who talked about your confabulated patient who talked about the price of beef for sessions at a time? - Yes it is, I just checked - a post from August 29, 2006 (I can't embed links - blogger is being, well, blogger) - but yes. Sometimes getting a handle on life can help abate symptoms. And sometimes just having a distraction for an hour can help too.

Anonymous said...

""So a new patient presents with the usual chief complaint of: "I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully." Patient after patient, all day long.""

I was glad for the next sentence! ""no one has EVER presented (to me) with such a request"" because when I read that I thought...oh my Gosh! I did not present that way!! Ha ha ha!

Anonymous said...

I disagree with your concept that almost any conversation with a psychiatrist counts as psychotherapy as long as the participants say it is so. Surely there must be an approach and methodology that is learned and followed which is defined as psychotherapy. Length ought to have some bearing as well; very short visit might be sufficient to check current mental state of the patient, but how much therapy could be done in 10 minutes or 15? or by a psychiatrist oriented towards and trained for drug prescribing?

ClinkShrink said...

TP: It does seem surprising, but therapy (or therapeutic interventions) can take place during a med check. Roy has had this experience on his consult-liaison service, and I've written about it here. People might say that's not psychotherapy even though my patients found it lifesaving. Talking about the price of beef might be life-saving, even if it's not exactly therapy. Go figure, at this point I say do whatever works.

I think the bigger question to ask is, do you consider it therapy when someone goes into therapy solely for the sake of experiencing therapy, like in the old days when everyone had to be analyzed. Do people even still do that anymore? Better yet, should insurance pay for it? (I know, those folks most likely pay out of pocket.) Just thinking out loud.

Jackie said...

When you say "and hopefully someone finds it helpful" it sounds like you have doubts on the helpfulness of psychotherapy? I mean, don't you regularly see how psychotherapy IS helpful to your patients? Or is it not that clear to you... I know you've posted in the past about wondering how a conversation about something mundane could be helpful.

Novalis said...

These days, if a patient entered the ER with such complaints, there may be an unseemly scrum as psychiatrists from the surrounding area would converge in a minor melee to compete to provide services to this paragon of a patient.

Alternative universe SNL skit: Psychiatrist (gleefully throwing his prescription pad aside), thrusting one colleague behind him and knocking another to the floor, asks introspective, insightful patient on hospital gurney, "And how does that make you feel?"

Anonymous said...

Hmm...I'm supposed to be having something that is therapy, but it sure doesn't ever seem like it. Sort of the reverse situation.

Anonymous said...

Good question - when does psychotherapy become psychotherapy? If you have a meaningful conversation with a friend over a cup of coffee, isn't that therapeutic as well? But that's not therapy because it's not structured as such (no therapist-client relationship for a start, although you may play that role with each other). I hear what you're saying about how a med check can be therapy but as a psychologist I would say there are degrees or types of therapy. Psychotherapy for me is predominantly a 'talking cure' structured over at least a few sessions which are regular, time-bound etc.

Anonymous said...

I've been reading your blog for a while - this is a great post, as is the previous one on DSM v.

I've passed on the Kreative Blogging award to you, as I love to read your site.

Head to to see what I wrote - basically you list 6 things you love, then nominate six blogs for the award. It's fun, and creates some great links you might never have made before!

FooFoo5 said...

I found this to be a most fascinating exploration of "community psychiatry" and the role of the psychiatrist in the provision of services. I suspect that the "definer" of "what is therapy," for the practical purpose of fee-for-service, is and will be insurance companies for all but patients that can pay "out-of-pocket." And I emphasize "therapy" as a billable service and therapeutic as an action. Being directly affiliated with a major medical school, I could also argue, with some prejudice, that "psychiatrists of the future" have little to no practical training as "psychotherapists," and are increasingly inappropriate providers of "therapy" services. Could a psychiatrist "survive" as a "therapist" without providing 90862? With appropriate respect, psychologists & social workers do so. But would a psychiatrist do so? I believe that it would be waste of significant training and experience as a physician. As described in Irvin Yalom's Existential Psychotherapy, pretty much everything we do, from the first call forward, is therapeutic, but the provision of "therapy" is a very different & distinguishable matter.

Dinah said...

Encounters of all types (15 minute med checks, coffee with a friend definitely) can yield interesting revelations or life-changing insights, and many things, including chocolate, can feel 'therapeutic.' I do think that calling 'psychotherapy' requires regular meetings with certain boundaries and parameters simply by definition. I'm just not sure what the exact parameters are-- is a 20 minute session scheduled monthly a med check (90862) while a 25 minute session scheduled monthly a psychotherapy session (90805)? So, TP, I think we agree.
I'll add that not all psychotherapy is therapeutic! Ah, but I'm not anti-therapy at all (on the contrary) and I do believe it's extremely helpful to lots of people.

There are many types of psychotherapy and some of these impose fairly specific structures (eg the couch, or the structure of cbt, etc) upon the subject matter being discussed.

FooFoo5-- you lost me-- you believe it's a waste of training as a physician to have psychiatrists doing psychotherapy? Or did I misread? I think a lot of folk probably agree with this-- maybe it's own blog post.

Anonymous said...

""I think the bigger question to ask is, do you consider it therapy when someone goes into therapy solely for the sake of experiencing therapy, like in the old days when everyone had to be analyzed.""

I never met anyone like that, though psychiatrists in training might fall into that category, and perhaps patients who continue therapy well past a crisis. I'd still consider it therapy.

""therapy (or therapeutic interventions) can take place during a med check.""" That can work I suppose if the med discussion ends quickly and both are motivated or inclined to go into a psychotherapeutic mode. It's a pity in such a case that funds don't exist (I am guessing) for a longer session. On the whole it seems that a lot more psych services are needed than available.

shraddha said...

The CPT coding can be really tricky.
I recently read somewhere that a mom had 25 weeker, surviving triplet.
They needed to get him assessed by a psychologist for his readiness for Kindergarten.
He did have low cognitive skills but no way near mentally retarted.
He was given the wrong code of mild mental retardation and they came to know through insurance that because of that ,the bills were not being payed!
Psychologist was so sorry for the mishap and repeatedly corrected that no mental retardation was present but just thinking of trauma the mom went through till it was sorted out was just too sad!


Neuroskeptic said...

Isn't there a (messy but important) distinction between unstructured "counseling" and structured "psychotherapy"? Isn't that what we're talking about here?

Does Counseling have a code?

Aqua said...

"I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully."

My first thought when I read this was that before I knew I had MDD, these are some of the thoughts that raced through my head.

Even now in therapy addressing these is intensely important to me. I have so much anxiety and angst over "why am I here, and why am I not able to live up to my potential. How can I find and bring purpose and meaning into my life. Those thoughts really fuel my depression I was sorry to hear you were being sarcastic. I thought lots of people felt the same way.

Anonymous said...

What's the CPT code for chocolate?

Anonymous said...

Actually, I presented to my psychiatrist with words nearly the same as the sarcastic quote. The work we are doing is psychotherapy. He is a psychiatrist but there is no medical tx, no dx. Any sx are seen as things to work through - find the cause rather than mask it.
My opinion is without regular time, frequency, duration, fee and so forth established and agreed upon in advance and adhered to by both the time spent may well be therapeutic but is not psychotherapy per se.


Rach said...

Who says there needs to be a diagnosis or defined symptoms in order for psychotherapy to be successful or helpful? Anonymous (comment 17) - I don't know why you don't consider your treatment with your psychiatrist to be psychotherapy. If you have formally (or informally) defined goals that you'd like to work towards with your psychiatrist, I would consider that to be a form of psychotherapy.

In fact, I would argue it's proactive and preventative psychotherapy - which is becoming less and less prevalent these days.

Anonymous said...

I do my own med checks, pour a few stiff drinks, take the phone off the hook. Now that is therapy.Al the rest is blah blah yap yap.

My shrink is in Vegas and I haven't noticed.

Anonymous said...

Now that my shrink has taken a salaried position with a treatment center, med checks have gone from 15-20 minutes down to 10 minutes, and the price has doubled.

I'm so mad, the only information he gets out of me is the basic medical stuff needed to write a prescription. Believe me, there's NO therapy going on during these med checks.

I'm thinking of switching over to the University mood disorders clinic, where you get a different resident every six months. Same level of treatment, half the travel time. >:(

Esther said...

I've had experience with billing and getting authorizations for med checks with psychotherapy. I agree that having a conversation about something other than the meds usually constitutes therapy (not hi, how are you doing, but actually helping the patient process feelings and stuff). After that the insurance company gets to play havoc with the billing codes -- it's like a game. There was one psychiatrist I worked with who routinely did 90807s (pediatric psychiatrist) and sometimes I had a lot of trouble getting the insurance companies to pay up. They would want me to call it a 90806 and I would have to point out that a med check was included. There were some companies that did not allow 90805s only 90862s and I never could figure out the real difference between the two. I would just ask the psychiatrist to write the note as a 90862 (their call, not mine) and make sure the correct code was on the bill.

From my own experience I think the billing codes are all just a way to make people jump through dozens of hoops and have to hire people like me to figure out ways to get the doctor paid. I really wish it could be simpler and the doctor could just do what is necessary to help the patient and then bill it as what it is.