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Is doing therapy as a psych NP realistic?

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by Kaelif2015 Kaelif2015 (New) New

PMHNP Student 2021

Specializes in APRN, FNP-BC, Neuro, ICU, ER, Admin.

On 10/15/2020 at 5:49 PM, umbdude said:

It is possible. However, the demand for psych NPs to do a lot of therapy is minimal at best. You will likely have to create your own path by working in a private practice that is willing to accommodate your interests or go solo. My guess is that your income will reflect that of a therapist, not a typical PMHNP. However, some therapists do make very good money in private practice. But those therapists generally have advanced psychotherapy training such as PsyD, clinical psychology, or to a lesser extent, LCSW.

Just my two cents...the psych NP path really does not make sense if your interest lies primarily in psychotherapy. We're trained almost exclusively in the biomedical/nursing model, from A&P in pre-reqs to psychopharm and diagnostics in medically complex patients during PMHNP program. Graduating from a psych NP Program doesn't mean you'll be an expert, and that learning will go on. If your interest isn't in psychopharm and medical science, your knowledge base could fall behind rapidly.

But the most crucial issue is that the psychotherapy training in a psych NP Program is extremely limited. You will likely put in a lot of additional time and money to get certifications after graduation. It'll probably take years to feel the level of competence that a PsyD or LCSW have. 

Thanks for sharing your wisdom

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

1 hour ago, PMHNP Student 2021 said:

Thanks for sharing your wisdom

Again what is the difference between "doing alot of therapy" and doing medication management with therapy add on codes? I do lifestyle interventions, therapeutic approaches such as gratitude journaling, and other inputs and get paid for it.  I have been audited by insurance companies and found to be in compliance. My clients often improve (hard to say if it is my therapy, my supplements or my medications) and I also encourage most of my clients to have a dedicated therapist. In an average day about three to four hours of my time is spent in an integrated therapy role. If I only billed for "medication management" I would probably earn around 15-20K per month but by also integrating therapy I earn between 25 and 30K per month seeing 12 to 18 patients per day (four days per week).  If can do this as a first year PMHNP why couldn't anyone else?

Edited by myoglobin
clarity

PMHNP Student 2021

Specializes in APRN, FNP-BC, Neuro, ICU, ER, Admin.

7 hours ago, myoglobin said:

Again what is the difference between "doing alot of therapy" and doing medication management with therapy add on codes? I do lifestyle interventions, therapeutic approaches such as gratitude journaling, and other inputs and get paid for it.  I have been audited by insurance companies and found to be in compliance. My clients often improve (hard to say if it is my therapy, my supplements or my medications) and I also encourage most of my clients to have a dedicated therapist. In an average day about three to four hours of my time is spent in an integrated therapy role. If I only billed for "medication management" I would probably earn around 15-20K per month but by also integrating therapy I earn between 25 and 30K per month seeing 12 to 18 patients per day (four days per week).  If can do this as a first year PMHNP why couldn't anyone else?

That's what I call holistic care.  Popping pills is the easy part, but therapy makes a huge difference.  And creates a balance for the patient.  Very nice. 

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

On 11/23/2020 at 9:36 PM, 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 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.

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

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.

Edited by MentalKlarity

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

16 hours ago, MentalKlarity said:

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.

It appears to be the norm to bill for supportive therapy - I do 20 minute follow up appts and that is enough time for basic supportive therapy.  

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

2 hours ago, FullGlass said:

It appears to be the norm to bill for supportive therapy - I do 20 minute follow up appts and that is enough time for basic supportive therapy.  

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

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

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.  

MentalKlarity, BSN, NP

Specializes in Psychiatry. Has 8 years experience.

40 minutes ago, FullGlass said:

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

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

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

1 hour ago, 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.

Just now, 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.

 

umbdude, MSN, NP

Specializes in Psych/Mental Health. Has 4 years experience.

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.

umbdude, MSN, NP

Specializes in Psych/Mental Health. Has 4 years experience.

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.