Psychotherapy can be readily integrated into brief ‘med-check’ psychiatry visits

Abbreviated, 15- to 30-minute medication visits have become common in psychiatry now that many insurers model their reimbursement patterns on internal medicine and surgery. To support practicing psychiatrists, a series of four columns in the Journal of Psychiatric Practice, describes how to feasibly combine brief psychotherapy with longitudinal pharmacotherapy. The final installment appears in the September issue.

The authors are psychiatrists Samuel Dotson, MD, of Northeast Georgia Health System in Gainesville, GA and Emory University in Atlanta; John C. Markowitz, MD, of New York State Psychiatric Institute and Columbia University in New York, NY; David Mintz, MD, of Austen Riggs Center in Stockbridge, MA; and Michael E. Thase, MD, of Corporal Michael J. Crescenz Veterans Affairs Medical Center and the University of Pennsylvania in Philadelphia.

The rationales for short-form combination therapy

“Since 2013, the American Medical Association has provided a Current Procedural Terminology therapy add-on code 90833 for billing encounters lasting between 16 and 37 minutes,” Eric M. Platkun, MD, the journal’s Psychotherapy Section Editor, notes in an introduction to the series. “Use of this code can often double the number of Relative Value Units for a visit, providing a strong financial incentive for its adoption.”

Abbreviated therapy can also expand access for patients who lack the resources or time for traditional psychotherapy, Dr. Dotson and his colleagues point out. Furthermore, incorporating psychotherapy into medication visits can improve the job satisfaction of psychiatrists who may otherwise feel reduced to the role of “just the prescriber.”

Practical approaches to success

The authors devote a full article to each of three psychotherapies: supportive, psychodynamic, and cognitive-behavioral. Using case studies, they discuss techniques for building elements of these therapies into brief medication visits. Many tips apply to all three psychotherapies:

• Have a framing discussion with the patient and document it in the treatment plan. The discussion should cover “the expected length of treatment, session duration, session frequency, expected fees, limitations of confidentiality, the plan for combined medication evaluations and psychotherapy services, and the specific modality and therapeutic tasks selected to achieve the patient’s treatment goals.”
• Discuss fees and their purpose during the initial consultation. For use of the 90833 code to be justifiable, patients must realize they’re engaging in psychotherapy.
• Maintain the same frequency and duration of visits. The 90833 code allows flexibility in session length (16 to 37 minutes), but consistency is important for the therapeutic process.
• Avoid taking a new approach at subsequent sessions, which can happen because of the wide spacing between medication visits. Reference prior discussions and maintain thematic continuity. If a psychotherapeutic approach isn’t working, agree with the patient on a shift from one evidence-based technique to another.
• Document the encounter carefully, designating a section of the combined note to the psychotherapy content and treatment plan. Describe the specific therapy and techniques employed and succinctly justify how they address the patient’s treatment goals.
• Work within unreasonable insurance demands. The 90833 code encourages psychotherapy time to be exclusive from time spent on medication evaluation and management services, which contradicts optimal clinical work. Offer a good faith estimate of the time spent on psychotherapy: a total visit length of 30 minutes is likely to be the minimum reasonable length for combined visits, unless 20-minute visits are paired with blocked administrative time later in the day. In some systems, AI scribes can track psychotherapy versus pharmacotherapy time as the physician toggles between the two modes on their computer.

The authors note that prescribers offering psychodynamic therapy should take care to avoid creating a competing psychotherapy if the patient is consulting a separate psychotherapist: “It is then prudent to restrict psychodynamic activity to supporting the patient’s healthy use of pharmacotherapy.”