What is Psychotherapy and What’s in A Code?

 

After a recent discussion about psychotherapy done in psychiatric treatment – I decided to write this post in order to capture the complexity of some of these sessions. I hope that this post serves multiple purposes including a demonstration about how business management affects psychiatric care and the range of services that people receive in psychiatric follow up appointments. The audience for this post will be people seeking psychiatric services, psychiatrists of all orientations, and anyone interested in quality psychiatric care.

The fundamental unit of psychiatric care comes down to what tasks need to be completed in a set time frame and there are a lot of variables. Rather than list those variables – it is probably easier to describe a limited or rationed task scenario and compare that to an abundant task scenario.  Most peoples experience with psychiatrists in the US will fall somewhere between the extremes.  From a scheduling perspective there are no assurances that what a patient needs on a particular day will be the session they are scheduled for.

In the most limited care, the patient is seen for follow up or “medication management”.  These visits developed as part of a coding scheme that suggested that psychiatrists could see patients for very brief (5’-15’) periods of time with an exclusive focus on the medication a person was taking, whether it was effective, and whether they were experiencing any side effects. To speed up the process, many clinics have templates that are rapid checklists of symptoms and side effects.  In some cases, as the patient speaks the psychiatrist is checking off items on the list so that at the end of the session, a couple of sentences can be typed and the note is complete. Depending on the setting, additional information that might be acquired in the rooming procedure during a standard medical appointment (like pulse and blood pressure) may or may not be collected. Before psychiatrists started using standard billing codes like the rest of medicine, there were codes that assumed this limited care could be completed in anywhere from 5’-15’.  As far as I know - no other medical specialty had codes that were as restrictive.  In some clinics patients would be seen for that period of time every 6 months.  That duration and frequency of medication focused visits might work well for some people, but there is an understandable concern about quality when it is applied on a population wide basis. That concern is amplified where patients have more medical and psychiatric complexity (high risk for medical or psychiatric complications).   

At the other extreme, a psychiatrist may see a patient for 30-60 minutes in follow-up. A psychiatrist who typically sees people for 30 minutes would review the efficacy and side effects of any psychiatric medication.  They also may cover more medical or neurological considerations and following another condition like the patient’s problem with hypertension, diabetes, or neurological conditions.  In the remaining time, there is a detailed discussion with the patient.  In the case of a 50'- 60’ appointment, the psychiatrist is most certainly providing psychotherapy in addition to medical treatment. They may be providing psychotherapy exclusively.  Standard billing codes can be used, there are also psychotherapy add on codes and a separate psychotherapy code. Over the years, a lot has been written about the financial incentive for seeing many more of the briefer visits per hour than longer sessions involving psychotherapy. Practice setting tends to be the overriding factor.  If you are employed in a clinic or hospital, there is some administrator telling you how many people you need to see in a day.  That number is referred to as physician productivity.

There is a lot of confusion about what constitutes psychotherapy. At its core, psychotherapy is a teaching experience where the therapist attempts to assist the patient in solving problems that complicate their psychiatric disorder or affect their ability to adapt to life situations.  That can cover a lot of ground including inflexible thought patterns, stressful relationships and current or past stressors. It can also be a very focal problem that might require some directive education like sleep hygiene, diet, and exercise modifications. The teaching needs to occur in the context of a relationship that is both empathic and collaborative.  That collaboration is often referred to as the therapeutic alliance to indicate that the physician/therapist and the patient are aligned to focus on and resolve a mutually agreed upon set of problems. The common view of psychotherapy is that it needs to be long in duration and that the therapist “analyzes” the patient during that time. That description comes from psychoanalytic therapy that is a very specific therapy done be relatively few psychiatrists and it does not represent most of the brief psychotherapy done in treatment sessions.

There has not been a lot of study of psychotherapy in psychiatry in the real world. The best single study by Mojtabai and Olfson (1) and it is the most often quoted.  The most notorious quote is:

“ …..third-party reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits.”

That led to the expected provocative articles about psychiatrists abandoning psychotherapy or being too motivated by money.  The reality of what it takes to keep a practice open in the face of paltry reimbursement was never mentioned. Some articles got so extreme they called for the end of psychiatry, replacing the greedy psychiatrists with therapists trained to prescribe. The authors of the article provide a much more balanced perspective including their opinion that many psychiatrists were still providing some kind of therapy and that their measures of what constituted therapy may have undercounted the therapy provided.

Polarized viewpoints of what actually occurs when a psychiatrist sees a patient probably described very little of what happens in real life sessions. From working in various settings with psychiatrists of three generations, there are many styles of practice and how psychotherapy is integrated – even into very brief sessions.  I was fortunate enough to work with a psychiatrist who ran a clozapine clinic and a separate clinic for long-acting injectable medications.  Both clinics were probably the largest in the state. He would typically see people in 20’-30’ appointments based on the complexity of the care they needed on that particular day. He was an expert in psychopharmacology and medicine as it applied to that patient population. But more than that he was empathic and knew the relevant life details of all of his patients. There was obviously a high degree of patient satisfaction and engagement in treatment.  One of the obvious markers of his success was patient interest in this physician after he made a career change.  His former patients would approach me in the hallway and ask me how he was doing or if I had heard from him. They would talk about him in the most positive terms. I don't recall seeing that happen with any other psychiatrist who moved on.

Papers on the minimum time needed to provide a psychotherapeutic encounter have been written for the past 40 years now. With the advent of managed care – many of them emphasize how the rationing aspect has reduced the time for both verbal and medical interventions. The latest guidelines for residency training emphasize the need to learn psychotherapy but beyond advanced interviewing techniques cognitive behavioral therapy or CBT seems to be the predominate paradigm – even though residents are still exposed to a variety of paradigms from their supervisors and mentors. 

The best single paper I have found that describes the psychotherapeutic aspect of medical treatment within the confines of a “medication management” session and its considerable constraints was written in 2018 (2).  The authors argue for the need for a human-to-human connection consistent with the existential orientation in psychiatry in order for treatment with medications to work.  The main features described are empathic listening and alliance building. One of the primary ways they are realized in the sessions is a focus on the patients own description of the problems or progress. 

As I read through this paper, I realized that I had been conducting outpatient visits in this manner over the course of my career but that nobody had previously described it in these terms or suggested why it had been so successful.  But even as I read this brief paper – I realized that the description was incomplete. It did not describe the many active psychotherapeutic interventions that I had used over the years.  I learned most of them as supportive psychotherapy in residency and they include interventions that would now be described as behavior therapy, cognitive behavioral therapy, and brief psychodynamic therapy and they all happened in the constraints of brief sessions that were generally 20-30 minutes long – in addition to whatever I needed to cover about the medications and other medical conditions.

These 20’-30’ sessions are currently No Man’s Land in the field of psychiatry. It is easy to extremely pessimistic about them.  As I previously noted they can be a political football – since any bias can be projected onto them. That is probably why there has been so little research in the area. It is as if the managed care and CMS template for these codes is an inescapable reality. Everything on the template is all that occurs in one of these sessions. I would propose a thought experiment to counter. If you are a psychiatrist seeing patients in these sessions and billing these codes – do you cover more information than what is in the bullet points for these sessions? Is the patient predictable from session to session – is more lengthy clarification needed? Are there any sessions where the entire session has very little to do with medications?  Are there any sessions dedicated to crisis intervention and only verbal interactions about that crisis? Do you see family members during these sessions and discuss their concerns? When you assess whether a person is experiencing suicidal thoughts do you know how to discuss them in a therapeutic manner?  If the answer to any of these questions is yes – it is highly likely that some form of psychotherapy is happening – even if you do not consciously pull up a psychotherapy technique that you learned and used in the past.  That psychotherapy happens whether you decide to record it on a template or not.

I think this area requires a lot more study. The information transfer between two people that can occur in 20’-30’ minutes is vast – even if it is semi-structured. The first step is determining what really happens in these brief sessions.  If anyone does that study, I think we will find out that the treatment that happens is much more than medication management.

 George Dawson, MD, DFAPA

 

References:

1:  Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008 Aug;65(8):962-70. doi: 10.1001/archpsyc.65.8.962.

2:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177.

Graphics Credit:

Photo by Eduardo Colon, MD