Psychotherapy and psychopharmacology utilization following repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder.

Lifetime prevalence of major depressive disorder (MDD) among a sample of adults in the United States has been reported as over 16%. Repetitive transcranial magnetic stimulation (rTMS) has become a treatment option for a subset of treatment-refractory patients with MDD. In a population of 159 commercial health plan individuals, we used claims data to compare utilization of antidepressants, antipsychotics, and psychotherapy during the one-year time period prior to rTMS initiation to the one-year time period starting 60 days after rTMS initiation. Both antidepressant and antipsychotic use declined significantly from three months pre-rTMS compared to each of four quarterly post-rTMS time points. Psychotherapy utilization also significantly declined post-rTMS compared to pre-rTMS. The reduction in medication utilization could reflect clinical improvement of the study population, and the absence of even greater reductions in utilization likely reflects the lack of clinical guidelines for antidepressant prescribing in the aftermath of rTMS treatment.

The new, confusing CPT codes: tips for documenting and billing to get paid what you deserve.

As of January 1, 2013, psychiatrists should be billing for services by using Evaluation and Management Current Procedural Terminology (CPT) codes for any encounter related to medical services. Because detailed information about these CPT codes became available only toward the end of 2012, clinicians had little time to be trained in their use, resulting in widespread confusion about when and how to use these codes for reimbursement. The authors describe strategies that psychiatrists can use to ensure appropriate reimbursement for patient care, such as how to code the initial psychiatric evaluation, acute or chronic conditions, medical decision-making complexity, psychotherapy, counseling, coordination of care, and crisis care. The authors suggest use of templates, with checklists, during patient examinations to facilitate documentation.

Optimizing managed care peer reviews: turning a "Doc to Doc" talk into better advocacy for psychiatric inpatients.

Clinicians often resent behavioral health managed care peer reviews. However, such reviews need not be onerous. This Open Forum, written by managed care physician reviewers, attempts to help attending psychiatrists, specifically those on inpatient units, achieve more satisfying outcomes for patients by adhering to a few basic principles. Beyond the level-of-care guidelines, attending psychiatrists are advised to focus on immediate acuity, along with specific life events that may have immediate impact on the patient's well-being. A clear diagnosis, relevant treatment plan, salient updates, and strategies for preventing readmission can justify additional treatment time. By contrast, "time-based treatments," dispositional issues, or a patient's lack of acceptance or effective use of treatment are harder to justify.