Transcranial Magnetic Stimulation or TMS therapy is widely used by Physiatrists to treat certain types of Major Depressive Disorder in adult patients. While it is the provider’s responsibility to determine whether a patient may benefit from TMS treatment, it the job of the biller to process all paper work for pre and post visit correctly in order to get paid for the services.
Pre-certification of insurances coverage for TMS therapy is a must. Majority of the insurances will cover this service when deemed necessary. One major exception is Medicaid. Billers must check with local Medicaid providers for coverage information. Patient’s previous medical records must indicate all methods of treatment done for the condition. Have the doctor review and approve all related exam notes and medical records before submitting to insurance. In certain instances, medical director from the insurance company might contact the provider directly for more information. Once approved by insurance, patient must sign a consent to receive the treatment. TMS treatment therapy is done over 4 – 6 weeks period, in 20-36 sessions. Our suggestion is to get approval for at least 3 months to cover for any missed or delayed appointments.
CPT 90867 will be billed for the first treatment and CPT 90868 will be billed for subsequent encounters. For certain patients, doctor might need to do a re-determination of the Motor Threshold (MT); in that case, it is appropriate to bill CPT 90869. Claim form will have the CPT codes and supporting diagnosis codes. No modifier is needed for billing TMS services.
It is very important to check with all participating insurances if TMS is a covered benefit under the provider’s contract. If not, biller must make formal application to add TMS CPT codes to the contract and obtain a copy of the updated contract before treatment begins. If provider feels the reimbursement rate is low for any insurance, formal application for fee negotiation can be submitted. Always obtain a copy of insurance Fee schedules to keep in file in order to make sure provider is getting reimbursed according to the contract.
Estimated reimbursements for TMS Therapy:
Tricare Commercial Insurance
90867-$400 90687- $300
90868- $250-300 90868- $170-250
90869- $350-400 90869- $250-300
If your practice is having difficulty in getting payment for TMS therapy or having any other Behavioral Health claim payment issues, please feel free to contact Medical Billing Strategies (MedBillingStrategies.com) so that we can assist you in navigating through the insurance maze.