How Many Mental Health Patients Can I See in a Day?

Carolyn Buppert, NP, JD

Disclosures

November 30, 2010

Question

How many mental health patients can a CNS or NP see in a day -- follow-ups, medication management, intakes, and urgent add-ons?

Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert, PC, Bethesda, Maryland

Mental health diagnosis and therapy don't always fit perfectly into a time slot, but neither do internal medicine and gynecology visits, where behavioral, cultural, and social issues often commingle with somatic conditions. As is always the case when talking about patient scheduling, there is an ideal and there is real life.

Ideally, a clinical nurse specialist (CNS) or nurse practitioner (NP) working in mental health would have slots in the appointment schedule for intakes (diagnostic interview examinations), follow-ups (individual psychotherapy), and medication management, and some space would be allotted for urgent add-ons, which could be diagnostic interviews, follow-ups, or medication management. The relevant CPT codes for each of these 3 types of visit are stated in Current Procedural Terminology (CPT). CPT provides no face-to-face time associated with the diagnostic interview examination, but it is safe to say that an hour is needed. Follow-ups or weekly psychotherapy could be 20 to 75 minutes, and CPT codes exist for 20-30 minutes, 45-50 minutes, and 75-80 minutes.

Medication management is often billed using the evaluation/management (E/M) CPT codes. The mid-level E/M visit is expected to take 15 minutes, according to CPT, and the range of times associated with the E/M CPT codes are 10-40 minutes. If, during the medication management visit, the NP spends more than 50% of the face-to-face time explaining lab results, prognosis, or treatment options; giving instructions for treatment; discussing the importance of compliance or how to reduce risk factors; or providing patient and family education in general, then bill the CPT code for evaluation/management that corresponds with the time spent.

It probably makes sense to schedule medication management visits for 15 minutes; don't plan to conduct psychotherapy during those visits. However, if the clinician does perform psychotherapy and medical management, there are CPT codes to cover those tasks. Check with your payers to determine whether they have any rules governing psychotherapy and medication management at the same visit.

From the standpoint of the clinician's mental health and also from a financial standpoint, the ideal clinic day is one when all of the patients who are supposed to show up do show up, and no additional patients show up. The next best thing would be a day when some patients don't show up, and some unexpected patients do show up, and the scheduled time is just right. However, there will be days when there are many no-shows and not many urgent add-ons and other days with too many patients to handle.

When trying to develop a scheduling template, first collect data on your no-show rate, your rate of urgent add-ons, the need for new patient time slots, for regular psychotherapy time slots, and for medication management slots. For example, a reasonable daily schedule for an 8-hour day might be:

  • 1 new patient diagnostic interview (1 hour);

  • 4 one-hour slots for psychotherapy (45-50 minutes face to face with the patient, 5 minutes for documentation, and 5 minutes for a bathroom break);

  • 8 medication management visits; and

  • 1 unfilled hour at the end of the day, which could be filled during the day with an urgent add-on.

I ran the numbers using Medicare's fees, and if the collections are done right, the patients and insurers pay the bills, and everyone shows up, this schedule should bring in almost $1000 per day. If it doesn't bring in that much, then someone should conduct an analysis of denials, bad debts, whether the fee schedules need to be renegotiated, and the billing and collection process, in general, to see where the problems lie. If this schedule isn't for you, construct your own and plug in the relevant CPT codes to calculate whether your schedule can support you and your practice expenses.

processing....