Sunday, December 8, 2013

"The Controversial Therapy That Deliberately Enrages Patients"

A sharp-eyed friend (with the help of google) alerted me to a piece about ISTDP on a site I had not previously known,, with the above title.  You can read it here.

I made a few attempts to post a comment, but they didn't stick, maybe because I included my website URL (  Maury Yoszef did manage to get an intelligent comment up there, thanks Maury!

In any case, I thought I would post my comments here:
As an ISTDP practitioner, I'd like to comment on some aspects of this article that can be misleading.
As Dr. Said notes, ISTDP is based above all on a therapeutic alliance between the patient and therapist.  ISTDP therapists encourage patients to face painful, locked-away feelings, but for this to be effective it must happen in the context of a relationship where patients understand clearly that the therapist is acting in their best interests  People who try to imitate a naive idea of ISTDP as "antagonistic" or "badgering" rapidly find out that it is not effective and if anything makes patients worse.  Maintaining the appropriate level of intensity requires a great deal of skill and training.
 There is never a time in ISTDP when a patient "literally wants to kill the therapist," and if a patient of mine ever did, I might well "seek help from law enforcement"--but I've never had to, and I don't know an ISTDP therapist who has.  ISTDP is about helping patients to experience and observe feelings, understanding that feelings and impulses are very different from actions.  In the process of ISTDP therapy, therapists can be relentless in pointing out patients' self-defeating behaviors; this brings up a mix of positive and negative feelings toward the therapist, which can connect up to unconscious feelings of rage from early life.  When this happens, the patient may experience feelings of murderous rage directed toward the therapist, but patients are able to understand that these are feelings and impulses, not actions they actually want to carry out--in other words, the patient does not, in fact, "fly into a murderous rage."  Experiencing these feelings (among others) is often an essential element of ISTDP treatment, allowing access to additional material from early life.
While Dr. Said's own description of ISTDP seems generally accurate, there are a few points (on which he may have been inaccurately quoted) that I would take exception to.  First, there HAS been quite a bit of research on ISTDP, showing that it is effective, though more is definitely needed.  Some of the research can be found on the web site ( of one of—if not the—foremost ISTDP researcher, Dr. Allan Abbass at Dalhousie University in Halifax, Nova Scotia.
Second, as many commenters have noted, it is absurd to say ISTDP "always works."  I have devoted a lot of time and energy to learning ISTDP because it treats a broader variety of patients in a more effective way than any other therapy I know.  But, for example, I would not treat a patient with schizophrenia, or a patient who is actively manic, with ISTDP.  And there are patients who, despite my best efforts, I have not been able to help.

Wednesday, January 9, 2013

DEA number renewal needs (non-existant) MCSR expiration date SOLUTION

OK, so I went to renew my DEA number... maybe I let it go a little longer than I should have.  (Are a lot of these posts starting with "OK"?  A little anxiety there, maybe?)

In addition to wanting to know your state controlled substance number (in Massachusetts, the MCSR), they (now) need to know the expiration date of your state certificate.

The only problem: there is no expiration date printed on the MCSR certificate.  The other only problem: when you search the web and get to the Mass DPH "FAQ" page, you are told that the certificates do not actually expire, they are "recalled" every few years at the pleasure of the Mass DPH.

Of course, that doesn't work on line at the DEA renewal site, so I printed the renewal form, filled in "N/A" under expiration date.  No dice; no renewal.  I called the DEA.  They said to call the DPH.  They (the DEA) seemed singularly uninterested in following up on this as a systemic issue.

I called the DPH.  Your certificate does in fact live forever until it dies.  The date on which it does not expire is three years from the issue date.  They also seemed singularly uninterested in following up on this as a systemic issue, though I suggested that if they post this information on their FAQs they might get fewer calls from people like me.

The DEA web site accepted this date and renewed my certificate pretty much on the spot.

Bottom line: use three years from the MCSR's date of issue for its expiration date on the DEA registration site, and it should work.

Monday, January 7, 2013

Evaluation & Management (E/M) "encounter form"

OK, we're all freaking out about the new psychiatry billing codes and the documentation requirements that go along with them, right?  Especially the E/M codes that replace the 90862 medication follow-up.

Over the weekend I made up a form that may help.  (You can skip to the end for the links to download it if you want to cut to the chase.)

The form can be printed out and filled in, either during a session, or afterwards; alternatively, it can be used for reference, to learn the coding system.  It captures—I think—all of the bits of documentation mentioned in the E/M documentation standards for psychiatry.  I tried to make it so that the various pieces are grouped together logically, with reasonably good design. It contains the standards and criteria for all the psychiatry E/M codes that I'm aware of: inpatient, outpatient, initial, subsequent, and all the levels.  (The reference sheet that I did that is available here only does levels 2-4, and only the outpatient follow-up codes; but it does include the psychotherapy codes and add-ons, and the simpler non-E/M evaluation codes, which this one doesn't.)

The form is not
  • something that contains all the elements of a complete medical record note; like the E/M documentation standards, it omits a number of very basic things like, uh, a medication list, a plan, etc.  I may do a second page at some point.
  • a guide to how you should conduct an interview
  • something that can be filled out on line, though it would be possible to turn it into an electronic form, and I may do that at some point
  • any kind of endorsement by me of this whole scheme of coding, billing, and documentation, although—even though I am someone who does not take care of the most complex medication patients—I am sympathetic with the idea that people who do should get paid more
I haven't used it yet, or piloted it in any significant way.  I sent it to a few people and the feedback was positive, so I think it's worth a try.  One of the complaints about the new system is that people worry that they will spend more time thinking about the documentation than about the patient.  It's true that people who are very anxious about the change may do that.  As I mentioned in the other post, I think that the vast majority of outpatient med visits will be 99213s, and these are not so hard to document.  So I believe it's possible to get familiar with the system while we're doing pretty much what we've been doing, and we'll need to learn to adequately document what we've been doing to meet the standards. I think that for outpatient psychiatrists, if you start by using the non-E/M code for initial visits, and you try to understand the difference between 99212 and 99213, all of which is outlined on the other sheet, you will be off to a good start and in fact you may have done everything you need to do.  Others will want to use 99214, and the E/M codes for initial visits.  More power to them.

Some ways you might use it:
  • I originally thought of printing this form two-sided.  It should work well for that, but when I realized that the note will need more than is on the form, I thought I might print it on two pages and use the back for additional notes.  It should work fine for this as well because the name is repeated at the top of the second page.
  • Rather than using it in the session, you could sit down after a session and see where all the data you gathered fits on it, and then use it to see where you are in terms of coding.
  • It can be used as a way to understand the coding system.
As with the reference sheet, I am providing this in the spirit of "open source." There is a link to the pdf below, but you can also download the Word .doc file and change it.  You can redistribute it freely as is.  If you change it, you should just include attribution.  Easy.  Free.  (As mentioned on the other page: donations welcome, via the "Support" button on the right.)

Also as mentioned on the other page: this is a good faith reflction of my understanding as of the moment of the writing.  I am making no representation that it is entirely correct or problem-free, and the responsibility for your coding or documentation rests, as it always has, with you.  But I hope this helps.

So here are the links:
At the moment, the "current" version and the "original" versions are exactly the same, but if I change the form, as I expect I will from time to time, I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original.  Each intermediate version should have a blog entry so that it can be found as well.

Good luck!  Feedback welcome, as long as you're not blaming me for this whole imbroglio.

License info:

Creative Commons License
Psychiatry E/M Encounter Form by Nat Kuhn, MD is licensed under a Creative Commons Attribution 3.0 Unported License.

Sunday, January 6, 2013

Update to 2013 CPT Codes for Psychiatry

I tweaked the ROS section of history to have a complete list of systems, and better prompts.

I also modified the file names so that they have the date on them.  I will leave old versions up, to reduce possible confusion.  I'll try to remember to update the original post (at so that it links to the blog entry for the latest update.

I'm making progress on the form for sessions/encounters and I hope to post it soon.

2013 CPT Codes for Psychiatry pdf version
2013 CPT Codes for Psychiatry .doc version for revision/remixing; more info with original post at

Friday, January 4, 2013

New Psychiatry CPT Codes: Don't Panic

If you're a psychiatrist (or psychiatric RNCS) in the US reading this, you are almost certainly aware that all of our billing codes changed on Jan 1, 2013.  If you are like most of the psychiatrists I know—at least in private practice—you are at least somewhat freaked out by this.  If so, keep reading.  If not—for example, if you're not a psychiatrist in the US—stop reading this immediately and go do something more interesting, like... well, like just about anything other than memorizing a phone book.  (There used to be things called phone books...  never mind.)

I made up a one-sheet reference, which I think can help with the codes.  There are links to it at the bottom.

Here are some links that I've used for reference, trying to understand this.  The "little" APA has a helpful page with many links, most of which are pdfs available to both members and non-members, at  The "Overview of the 2013 Changes " will get you started; the last two pages, which are also included separately as "E/M Summary Guide: Coding by Key Components," were the single most helpful reference for the complexity-based E/M codes, which you will quickly realize are the only really challenging issue here.  I also found the "Patient Examples Outpatient E/M Visits" helpful.  And finally, the comprehensive reference seems to be "Evaluation and Management Services Guide from CMS ." (Note that while the APA site says that it "does not replace content found in the 1997 Documentation Guidelines for Evaluation and Management Services, abridged version for psychiatrists [listed above]," it seems to contain the full 1997 guidelines as an appendix, so I'm not exactly certain what they mean...)

My advice, at least at the beginning, is to avoid the E/M codes for initial visits, and use the generic initial evaluation code, which replaces 90801.  Some of the E/M codes for initial visits will probably end up reimbursing better than the generic code.  Again, my advice: save that for later.

Unfortunately you need to use the complexity-based E/M codes if you are doing psychotherapy and medications together (e.g., the old 90807), which you now need to code with a complexity-based E/M code and a psychotherapy "add-on."  I suspect I will mostly end up using 99212 and 99213, but some colleagues have pointed out that 99214 is workable, especially for those doing geriatric psychiatry.

So, with the exception of the initial-visit E/M codes, I boiled it down into a one-page reference, which anyone is free to redistribute as far and wide as they link.  Links are at the bottom of this page. When you click on that link, if the file opens in a browser window rather than downloading, you should just be able to go to "Save" in your browser's File menu to save the pdf or .doc file on your hard drive.  I am not charging for it (though in the spirit of "shareware" I'm happy to accept donations from anyone who feels so moved, see the "Support" button to the right).  I'm making it available as "open source" material under a Creative Commons license (more info at the bottom), which means that you could change it and redistribute it as long as you do so in compliance with the license (meaning that if you change it and distribute it to others you attribute the original). The license actually does not rule out commercial use.

Feedback and comments are welcome!  (I am aware, by the way, that I made one simplification: it is possible to hit the criteria on medical decision-making based on problem and data points alone, but I can't really ever see that happening without also hitting the risk criteria).

And of course, the obligatory disclaimer.  I am not an expert in this stuff, this is simply my best understanding of it.  It is quite possible that there are errors in the reference, and if you find any, please tell me.  But you are, as always, responsible for your own coding and documentation and I can't assume any responsibility for any problems that come up for anyone but me.

I've also made a form for taking notes in session (or for learning the system between sessions) which should make documentation and coding easier. More information at

So here are the links:
I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original.  Each intermediate version should have a blog entry so that it can be found as well.

The licensing information:

Creative Commons License

2013 CPT Codes for Psychiatry by Nat Kuhn, MD is licensed under a Creative Commons Attribution 3.0 Unported License.