Is doing therapy as a psych NP realistic?

What Members Are Saying (AI-Generated Summary)

Members are discussing the time required for medication management appointments, with some stating that the standard 20 minutes may not be necessary for all cases. They also talk about the financial aspects of different appointment lengths and codes, as well as the potential for nurse practitioners to provide therapy along with medication management. Additionally, users are sharing their experiences and perspectives on balancing therapy and medication management in their practice.

Im considering pursuing my psych NP but I know most psych NPs are med management focused and I would really want to incorporate a lot of therapy into my practice, I was wondering if this is a realistic goal? 

Specializes in ICU, trauma, neuro.
7 hours ago, FullGlass said:

You are missing the point.  Yes, PMHNPs can bill add-ons for therapy.  That doesn't mean they very well trained or qualified to provide it, unfortunately.  And it is not possible to provide good therapy in 15 or 20 minutes once a month or so.  The job description of most PMHNPs clearly focuses on med management.  The PMHNP curriculum is in no way adequate preparation for delivering serious talk therapy.  Poor quality therapy can also harm the patient.

I will agree that we should generally encourage clients to have "stand alone" therapists in addition to providing supportive therapy and medication management. However, in response to the primary post questions concerning whether or not it is possible to do a lot of therapy as a PMHNP I would assert that it is not only possible, but optimal and an essential part of what we do.  Again, rather than distressing over our limitations, I would rather celebrate the abundant opportunities that we have. Keep in mind you are free to expand your education to your heart's content. I am in the process of signing up for a $5,000 CBTi certification course which will take me about three to six months to complete for example and I will be one of the only providers (out of a practice with more than 200 therapists and 40 PMHNP's) who has this certification. I had also investigated a year long course which would give me ERP therapy for OCD certification, but that is beyond my ability to pursue at this point.

Specializes in psych/medical-surgical.
On 11/21/2020 at 1:49 PM, FullGlass said:

You are missing the point.

Your retorts are "theoretically" correct. We all know theory is often far from reality and that just because someone spends 3,000 hours at something, doesn't mean they are going to be good or better. You think if you spend 10,000 hours playing basketball that you can beat some kid that is physically built for it and more conditioned? Most likely not, but who has more time? Not the best example, but you get the point.

There are always going to be better and worse. There are patients that come to NPs because the Psychiatrist gave up or said they couldn't help the patient anymore. Guess that was part of the 10k hour training. To tell someone you can't help them. Even between other MD's that have 10k hours doing whatever, guess what? Outcomes are still highly variant based on the setting and provider that you have. Go look it up, it is well documented in literature.

There are still really good suggestions you can make based on your knowledge in 15-20 minute appointments. Did you know diet high in refined carbs contributes to depression? I'm in South so most everyone is metabolically unhealthy here. One of last people I saw in clinic was not exercising and eating really poorly. While I probably didn't correctly perform motivational interviewing or CBT, I hopefully open her eyes to making some changes that could help how she was feeling. And that is what we are there for. Not "no you can't offer other advise or therapy because it doesn't make economic sense" or "because it is not the normal." 

Really irks me how so many seem to stifle any semblance of creativity or lack the luster to smash the norm. Our profession will surely benefit from this type of belief.

Specializes in Psychiatric and Mental Health NP (PMHNP).
23 hours ago, adammRN said:

Your retorts are "theoretically" correct . . . Really irks me how so many seem to stifle any semblance of creativity or lack the luster to smash the norm. Our profession will surely benefit from this type of belief.

PMHNPs can certainly provide supportive therapy during their allotted appointment times, as well as advise on topics like nutrition.  My point is that they do not have the education or training, nor do most of them have enough time during their appointments to provide what most people would consider a regular talk therapy session.  We are NOT trained to the level that psychologists or LCSWs are to provide talk therapy.  And poorly conducted talk therapy can cause harm to the patient.  I have patients that have suffered severe physical and psychological trauma from living in war-torn countries and literally seeing family members tortured and killed in front of them.  That sort of trauma has to be handled very carefully and there is no way I am qualified to do that.  

As for psychiatrists, I don't know what that has to do with this topic.  Most of them aren't well trained in talk therapy, either, which is why they also focus on med mgt.

Specializes in ICU, trauma, neuro.
1 hour ago, FullGlass said:

PMHNPs can certainly provide supportive therapy during their allotted appointment times, as well as advise on topics like nutrition.  My point is that they do not have the education or training, nor do most of them have enough time during their appointments to provide what most people would consider a regular talk therapy session.  We are NOT trained to the level that psychologists or LCSWs are to provide talk therapy.  And poorly conducted talk therapy can cause harm to the patient.  I have patients that have suffered severe physical and psychological trauma from living in war-torn countries and literally seeing family members tortured and killed in front of them.  That sort of trauma has to be handled very carefully and there is no way I am qualified to do that.  

As for psychiatrists, I don't know what that has to do with this topic.  Most of them aren't well trained in talk therapy, either, which is why they also focus on med mgt.

The Psychiatrist that I trained with had an entire year of his residency focused on therapy. He said that although he enjoys therapy he only has time to do supportive therapy because the expectation was to see 3-4 patients per hour. My point was that most effective PMHNP's will do significant amounts of therapy in their jobs and will be expected by their employers to bill for it (unless doing time based billing in which case they will probably be required to see 3-4 patients per hour).  Indeed, it is the "complexity based" coding along with add on therapy codes that make PMHNP's relatively more valuable (and therefore higher paid) than FNP's. 

Specializes in ICU, trauma, neuro.

The question was whether or not you can do "a lot" of therapy as a PMHNP. I have between 10 and 15 30 min followups each day and my intakes are 90 min. The supportive therapy that I provide integrates CBT, CBT-I, lifestyle changes, and specific exercises, grounding approaches and other interventions. I also encourage most of my clients to have dedicated therapists. Insurance companies pay me about $100-$200 per hour in addition to what they pay me for the stand alone medication management. Thus my supportive therapy pays more than what many dedicated therapists earn. Thus, I suppose it is a matter of semantics. Note also at the place where I worked in school these same codes were also added except that our medication management appointments were only 20 min and the salary was 120K per year rather than the nearly 350K I earn now 1099.

Specializes in Psychiatry.

Read the whole thread and I must say I have worked as a PMHNP both in a position that was all med management and then my current position which has therapy as well. The norm is definitely the 15-20 min med management which employers love and there's no time for therapy.

I agree with myoglobin that if you can get 30 min appts and use therapy add on codes it's a much better practice flow. I have plenty of time with patients to discuss medications and then we move into therapy. I pull in elements of different types of therapy based on what they want to discuss. Many times it's just supportive, and ALL providers can learn to do supportive psychotherapy which is affirmation, praise, encouragement, etc. Sometimes we discuss elements of CBT and negative thoughts. Sometimes we discuss CBT-I concepts and sleep restructuring for insomnia. The point is that there are tons of resources out there to learn these concepts, and if you have 30+ min appts its possible to utilize and bill for them. Patients do MUCH better when you are listening to them and discussing their stressors and interventions rather than just throwing meds at them. We should definitely be billing for that extra time and work.

It is not, however, the norm. Prospective PMHNPS should understand that the vast majority of employers will utilize the 15 min med management appt. That's a stressful way to practice and you basically have time to just go over meds and prescribe and nothing else. If they ask you to bill add on therapy in that time it's unethical and fraudulent.

Specializes in Psychiatric and Mental Health NP (PMHNP).
53 minutes ago, MentalKlarity said:

That leaves 4 mins max for med management so it's easy to fall behind.

We specify how much time on therapy - I can do about 11 to 15 minutes.  

Specializes in ICU, trauma, neuro.
MentalKlarity said:

Ah, okay. What add on code allows 11-15 mins or do you not do an add on code?

I use 90833 which requires at least 16 minutes of therapy.  I do 30 minutes appointments. Most of the insurances that I take pay anywhere from $75.00 to $125.00 for this add on code on top of the 99214 or 99213.

myoglobin said:

I use 90833 which requires at least 16 minutes of therapy.  I do 30 minutes appointments. Most of the insurances that I take pay anywhere from $75.00 to $125.00 for this add on code on top of the 99214 or 99213.

Specializes in Psych/Mental Health.

Where I worked we don't do add-on because the appts are booked for 15-min (though realistically we spend 20 min). It's done that way because there's a huge need for psych prescriber and there's a large in-house behavioral health therapist group. If PMHNPs do 30-min f/u, the wait list will probably double (6-months). Not to mention, >90% of patients are on medicaid so a 90833 would add $10?

This isn't to say that we don't do supportive therapy with CBT/DBT/MI techniques. Anyone with some psych RN experience almost always do some of these skills by default. Is that really doing a lot of psychotherapy? That's subjective.

Specializes in Psych/Mental Health.
3 hours ago, FullGlass said:

We specify how much time on therapy - I can do about 11 to 15 minutes.  

The minimum requirement is 16 minutes and E/M must be based on MDM. I think if your appts are booked as 20-min and you're billing a lot of add-on, there's an increased risk of audit (from what I've heard).

Honestly my experience is that 4 minutes is rarely enough to go over meds...but the patients I have often have complex of med/psych/SUD conditions. 

Specializes in ICU, trauma, neuro.
14 hours ago, MentalKlarity said:

Same. I enjoy it. I get to spend more time with patients, don't feel as rushed, have half as many notes to complete and make the same or more than if I was trying to do 15 min med management 4x an hour.

Also my "cash rate" is $150.00 for a 30 min medication management appointment and $250.00 for a 90 minute intake. In these situations I also provide therapy but it is  "lumped in". About 10% of my patients pay cash.

Specializes in Psychiatric and Mental Health NP (PMHNP).

We use 90833.  I do not see how med mgt takes a full 20 minutes unless the pt is very complicated.  This is an outpatient practice and the most common issues are anxiety, depression, PTSD, ADHD, bipolar d/o.  If the pt is stable and doing well, how does med mgt require 20 minutes for simply something like Lexapro?  It doesn't.  How is your mood?  Good.  Sleeping well?  Yes.  Appetite?  Normal for me.  Anxiety?  Not any more.  Any troubling SE?  No.  That does not take 20 minutes.

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