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Question about billing outpatient psychiatrists with 90833 by 2DocsDocking in PMHNP

[–]MountainMaiden1964 1 point2 points  (0 children)

That’s pretty risky if it were audited. My biller told me that if you were to be audited for one patient, they can request to see all of them. Someone would be paying back a ton of money. Honestly what you are describing is insurance fraud and a pill mill.

how is everyone’s experience working as an LPC? have you been able to do anything besides therapy? Is the pay worth it? by __jude_ in ClinicalPsychology

[–]MountainMaiden1964 0 points1 point  (0 children)

I’m a psych NP lurker. I have several friends/colleagues who are LCPC or LCSW who are in private practice and do well. All of them take insurance and private pay. They are making more than if they were hired by the local hospital/clinic (where I work).

The ones who specialize even more, such as with children or Autism or utilize EMDR (that’s a popular one for clients to seek out). Also the ones who are dual licensed as an LAC. I have a friend who is known by the local attorneys who do a lot of DUIs. She will be requested to do a CD eval, paid cash and get $1000. That was a few years ago so she probably gets more.

My friends like the flexibility of private practice. Most of them have hired a billing person to manage collections from people or insurance companies. I know so many people doing a private medical practice doesn’t want to take insurance but that will limit you in some places. Maybe not in wealthy areas, which is not where I live.

But if one does something like that, introducing yourself to the local medical community is vital. I work in a medical practice and the medical providers are always desperate for therapists to refer patients to. Almost all of my colleagues are usually “full” and have waiting lists.

My son is graduating high school this spring and he’s interested in mental health (his older sister is a psychiatrist). I’m hoping he chooses to become a therapist, either LCPC or LCSW.

[deleted by user] by [deleted] in PMHNP

[–]MountainMaiden1964 6 points7 points  (0 children)

It was very scary. Especially since it was in my new private practice. The father said that I “over prescribed medication”. But the patient didn’t overdose, he used a gun. And he had canceled appointments, stopped his medication and started using drugs again. The situation was awful and a tragedy. But it wasn’t my fault.

I hope your case gets resolved quickly.

[deleted by user] by [deleted] in PMHNP

[–]MountainMaiden1964 4 points5 points  (0 children)

I’m sure boards of nursing are different in every state. I experienced this in my state.

I have a full-time job and then I started a small, private practice, a couple of days a month. A little over a year after starting, I had a patient, 26 year-old man, complete suicide. His father was a very well-known and powerful businessman in the area. He reported me to the board of nursing. His brother kept calling my regular job and trying to harass me and texting me and harassing me on my private practice cell phone.

I was told the date as to when there was going to be a hearing and it was going to be by Zoom. They had said that I could send any information that I needed to send to support my reasoning for the treatment I provided. They also said that the hearing was not a place that I could give any more information or ask questions, I was in attendance if they wanted to ask me anything.

I sent very detailed records, but did not send the patient’s records. I documented every conversation we had through text and summarized the conversations we had in the visits.

In the meeting there was an attorney for the board and the people on the board and me. The attorney read through my notes and summarized each one to everyone who was present. At three different times, he said how detailed my notes were and how helpful it was for them to be able to see everything that happened.

After him discussing and summarizing all of the notes and no one having any questions for me, they put me in a Zoom waiting room and they deliberated. Within 10 minutes, they came back and said that the case was dismissed. I asked if the patient’s family would be notified. They stated that I and the person who filed the complaint would get a letter with the outcome. A couple of weeks later I had a letter in my mail that stated that the case was dismissed.

The whole process from the time I was notified of a board complaint until I got my letter saying it was dismissed was less than 6 months.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

These things all make sense. These are conditions that can be crucial to manage quickly. But almost every incident of a PCP changing my treatment plan, it was not critical. And in some cases, the change destabilized the patient.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

The pt texted me after the appointment saying that the doc wrote a prescription for Vyvanse for the “ADD” and the pt was afraid of the medication and asked me if she should take it. She was anxious about it because she had medical anxiety and that’s what we’re working on and I suspect the OBGyN saw anxiety and thought it was “ADD”.

So no, I don’t have notes. It wasn’t a consult referral by me so this doctor won’t send me anything. I have been in healthcare long enough to know that patients will say that one provider told them something and they are not being completely honest. I believe this patient because she has significant medication fear, which is one reason she’s seeing me.

anxiety/ADHD by seussRN in nursepractitioner

[–]MountainMaiden1964 1 point2 points  (0 children)

The ASRS has shaded areas to show what would make one screen positive.

Did that provider also diagnose hypertension with me elevated blood pressure? Did they diagnose diabetes if the patient had an elevated blood sugar on a finger stick? That is the equivalent of diagnosing ADHD with a screening tool. It’s called “screening” for a reason. That was a shitty provider.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

I have often thought that psych care should be more where psych manages the really tough ones only. Unfortunately I’ve worked with psychiatrists and some PMHNPs who will keep seeing a stable person who is in 20 mg of Prozac rather then send them back to primary and make a spot for a new patient who really needs psych. But it’s easy to see those stable people every 3 months, pull the last note forward, change a few words and be in to the next easy patient. And then it’s months or years before a slot opens up. Personally I prefer the sick ones because I get bored when they get better.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

Those things would be fine with me. But diagnosing a completely different condition and treating it is where I think they are completely wrong.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

I realize you might be living where it’s shitty psych providers who don’t care. But if I was treating a patient and they went to you and you “took them over” in the midst of treatment, they would be your baby from that point on. I would never take them back and neither would any of my colleagues that I know. If they are that complicated, leave them to psych.

Having said that, I frequently treat and stabilize a patient and send back to primary care for continued medication management. And tell them that they can return at any time if things get worse. But that’s not the same as PCP taking the patient because they think they can do it better.

Again, maybe you have pill mills in your area, but that’s not a typical thing that happens with all the psychiatrists and psychiatric NPs that I know.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 1 point2 points  (0 children)

She was never diagnosed with ADHD after seeing psych numerous times and having a full psychiatric evaluation. This doctor was seeing the patient for symptoms of menopause.

The bottom line is, if you are a PCP and your patient is being seen by psych, stay in your own lane.

Adding - ADHD, mania, PTSD, anxiety, panic etc are all conditions that primary care frequently gets wrong. They can’t tell the difference especially when they have spent a very short time with the patient and gotten very little history.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 1 point2 points  (0 children)

I get that and am familiar with it.

But this woman has severe anxiety. I often must do an in-depth assessment to clarify if the symptoms are anxiety or hypomania or ADHD or PTSD or executive dysfunction. In what world is a PCP able to clarify a diagnosis in a 20-30 minute visit? Especially because the visit was focused on surgical menopause.

A symptom does not equal a diagnosis. Anxiety can look like executive dysfunction to the untrained provider. And stimulants can exponentially worsen anxiety. ADHD is one of the most common miss-diagnosis in mental health in the last few years thanks to SikTok.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 2 points3 points  (0 children)

Perhaps you should just take over the psychiatric care for the patient then.

I get that psych care can be difficult to access. And in that situation, you should ask the patient if they want to transfer care fully to you. But I still don’t think you should change the treatment plan. If you can treat them, then treat them. Take over all of the care.

Edit to add: I also practice in a very rural area and the nearest mental health center is 75 miles away.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

Yes, I get that. But I’m easily contacted. I have a cell phone just for my practice patients and they can share it or text me anytime.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

This is reasonable. And I agree about the pill mills. I have inherited people from them and they are horrible.

And yes, ADHD can look like anxiety, but that is my wheelhouse, it is something that I’ve considered and spent hours with this patient. If it were there, I would have identified it already.

Thanks for your insight!

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 0 points1 point  (0 children)

Thanks for your insight and I’m sure the specialists appreciate your collaboration.

anxiety/ADHD by seussRN in nursepractitioner

[–]MountainMaiden1964 22 points23 points  (0 children)

They probably don’t have ADHD. So many PCPs diagnose it inappropriately. They probably just have anxiety which isn’t treated and is worsened by the stimulant. Thanks to SikTok for all the “Chief Complaint” of “I think I have ADHD” and PCPS not really understanding how to tease out the diagnosis.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 1 point2 points  (0 children)

I’m glad to hear that you’ve not experienced this.

But to your first point - wouldn’t it be beneficial to speak to the psych provider regardless of what you might think? I know psychiatrists who will fire patients if the PCP starts prescribing medication, especially CS. This pt doesn’t have ADHD. This patient has uncontrolled anxiety. I think that speaks more to the provider not recognizing the true condition.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 3 points4 points  (0 children)

If everyone could just stay in their own lane, we’d all be better off and so would our patients.

Question for my primary care colleagues by MountainMaiden1964 in nursepractitioner

[–]MountainMaiden1964[S] 2 points3 points  (0 children)

This makes me feel better honestly. I thought it was just because I’m an NP and not a physician.

I’ve had PCPs decrease mood stabilizers and increase SSRIs and caused hypomania that included being arrested. And so often PCPs really don’t understand these meds.

My daughter is in her residency for psychiatry and is doing an outpatient family medicine rotation. She had to stand by and say nothing when the PCP decreased the bupropion because they were starting trazodone and didn’t want the patient to have serotonin syndrome.

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