Is doing therapy as a psych NP realistic?

Nursing Students NP Students Nursing Q/A

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.
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.

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

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.

I usually take my whole 30 minutes. I will usually do a PHQ, GAD-7 and an ADHD V1.1  or Yale Brown if relevant.  I will spend time reinforcing things like CBT-I, balance exercises (such as those supported by Dr. Hallowell in ADHD 2.0), gratitude journaling, supplements like Omega three fatty acids, DASH diet (which has a recent study supporting ADHD, but is also useful in addressing hypertension that can be an issue with ADHD meds).  I will talk about Podcasts like Dr. David Puder's Psychiatry and Psychotherapy Podcast and encourage clients to participate in the "book of the month club" (this month it is Victor Frankl's "Man's Search For Meaning" and his "logos therapy".  Honestly, I could use more time than 30minutes much of the time.  

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

The southeast does not seem to be a good work area for NPs.  I'm curious, how much does insurance pay for the standard 20 min follow up appts and the 40 to 50 min intake?

In Washington "my" average take for a 30min appointment (70%) averages around $150.00 for a 99214 plus 90833 NPT.  In Florida you could decrease that by about 10 to 20%.  For my 90 min intakes "my" portion is around $200-250 on average.  Thus, I do better on repeat clients.

myoglobin said:

I am a new graduate and I integrate therapy with every client. I use codes that pay me more for doing so.  Most of my therapeutic interventions are evidence based lifestyle and I heavily rely upon information from podcasts like The Carlat Report and Dr. David Puder's excellent podcast. However, having said that I almost always encourage my clients to see a dedicated therapist trained in the modality most suited to their needs be it CBT, CBT-T, CBT-I  EMDR, ERP, DBT or another approach.  Part of what we are trained to do as NP's (hopefully) is to identify the best evidence based therapies and then to facilitate clients receiving those therapies.  There are times when I have clients who's insurance will not pay for therapy (Medicare typically) where I will will make the followup appointments an hour rather than 30 minutes so that I can at least give them some therapy. I also almost always cover the basics of CBT(I) with anyone suffering sleep issues since it is perhaps the most evidence based intervention for insomnia, more effective in the long term than any supplement or RX.  Having 90 minute intakes and 30minute standard followups helps to create a solid opportunity to provide at least some therapy on an ongoing basis. Insurance compensates me usually in the $300 to $500 range for codes on intakes like 99205 along with 90838 and 90785 on my 90 minute intakes.  On my 30 minute followups I will often use the combination of 99214, 90833, and 90785 (where appropriate) and this compensates around $150-200 for most of my insurances for a 30 min visit.  Thus, I am getting compensated for the therapy that I offer and the time that it takes.

My wife often talks to former classmates (PMHNP) who charge $400.00 for intakes and $150.00 per 30 minute visit cash only without regard to whether or not it is therapy, prescribing, or a combination of the two. I am not to that point yet (and may never get there), but it is something to keep in mind ($300 x 32 billable hours per week times 48 weeks per year would gross around $460,800 per year if my math is correct. Not too bad). I probably get 20-30 calls or emails per week from my poorly written Psychology Today ad and my troll like picture., and many more appointments provided by the company that I work with. If I had a nice website and worked to build some Google reviews I suspect that I could generate many more leads, but such organizational precision is beyond my severely ADHD impacted brain.

This is super helpful! I am soon starting an accelerated BSN program and then would like to go on to become a PMHNP, and I'd like to use both medication in therapy in the treatment of my clients one day. I've been scouring the internet looking for descriptions of the role of therapy in the practice of a PMHNP, but it's been hard to find. That has made me think that providing therapy as a PMHNP is rare. But I also spoke with a few PMHNPs as well as a Psy D about the role of therapy as a PMHNP and it seems like I can boost my credentials as a therapist, outside of my MSN program, with additional trainings, certifications, residencies, etc. and carve out a niche for myself, probably in a private practice. 

In both of my conversations with a PMHNP and a Psy D, they both alluded to PMHNPs being more prescription heavy providers rather than therapists, and that being due to the money. I still have a handful of questions about how those things affect your pay and how insurance is billed, etc. Could I send you a message Myoglobin? I'm a new user to the site though, so I don't know if I have that ability yet.

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