Transcranial Magnetic Stimulation Billing: Cpt 90867–90869 With Modifier Updates

By Author: Charlie Robinson
Total Articles: 66
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Over the years, Transcranial Magnetic Stimulation (TMS) has progressed from a research-based approach to a widely accepted clinical treatment—especially for patients with major depressive disorder who don’t respond to medication. Approved by the FDA in 2008 for depression, TMS is now gaining traction in broader mental health applications.

As its clinical use expands, TMS has also received increased coverage from both public and private insurers. This growing demand makes it more important than ever for providers to maintain accurate billing practices. Mental health professionals must stay informed about the latest CPT codes, proper use of modifiers, and compliance with evolving insurance policies.

Here we break down the latest updates on TMS coding, modifiers, and billing practices to help ensure compliance and improve reimbursement efficiency.

Latest TMS Billing Changes
Recent insurance and Medicaid updates have improved access to TMS therapy, though billing and documentation requirements remain strict for approval and payment. Below are key updates:

• Coverage and Authorization Requirements
...
... Starting August 1, 2024, Medi-Cal will routinely cover CPT codes 90867, 90868, and 90869 for individuals aged 15 and older. However, a Treatment Authorization Request (TAR) remains necessary. Commercial insurers may also require pre-authorization, with varying documentation expectations. To secure approval, providers must clearly present the diagnosis, previous treatment efforts, planned sessions, and anticipated treatment results.

• Understanding Payer-Specific Guidelines
Coverage criteria differ across insurers, including limits on session frequency, required ICD-10 codes (such as F32.2 for major depressive disorder), and age restrictions. Verifying each patient’s insurance rules in advance helps prevent claim rejections and ensures a smoother billing process.

• Proper Documentation for Smooth Claims
Thorough documentation is vital for successful reimbursement. Each TMS session should include details such as the patient's identifiers, coil placement, motor threshold, session timing, and the patient’s response. Inadequate records often result in denials, delays, or audits. Implementing EMR templates can streamline this process and support compliance.

CPT Coding for TMS Treatment

TMS billing relies on specific CPT codes based on the service provided during each session:
• CPT Code 90867 – Initial Session
Used only once per treatment cycle, this code covers preparation and determining motor thresholds. Documentation should include the initial assessment, motor threshold settings, and signed patient consent.
• CPT Code 90868 – Subsequent Sessions
Applied to follow-up sessions after the initial setup. These sessions must include records of treatment duration, coil positioning, and patient feedback. It cannot be billed alongside 90869 on the same day.
• CPT Code 90869 – Re-Mapping Only
This code applies when motor threshold recalculations are performed without actual treatment. It’s used when the protocol changes or the patient’s condition shifts significantly. It should not be billed with 90867 or 90868 on the same date, and justification must be clearly documented.

Modifier Use in TMS Billing

Modifiers help clarify that services performed on the same day are medically necessary and separate, reducing the risk of billing denials:
• Modifier 25
Separate E/M Service
Added when a provider performs a distinct E/M (evaluation and management) service during the same visit as a TMS session. For example, if medication side effects are reviewed or unrelated issues are addressed, this modifier is applied to the E/M code (e.g., 99213). Separate documentation is essential.

• Modifier 59
Distinct Procedural Service
Used when another non-E/M service like psychotherapy is provided on the same day as TMS but at a different time or location. For instance, a patient may receive TMS in the morning and psychotherapy later in the day. Documentation must clearly differentiate the two sessions.
Proper Use of Modifiers
Correct use of modifiers ensures full reimbursement and avoids claims being bundled or denied. Both Modifier 25 and 59 require solid documentation. However, these should only be used when services are genuinely distinct—not routinely.

Conclusion:
Billing for TMS therapy can be particularly challenging due to its procedural nature, technical documentation needs, payer-specific coverage rules, and evolving reimbursement policies. Errors in coding or incomplete documentation can lead to financial losses, compliance issues, and disruption in patient care.
As TMS continues to be a standard treatment option for medication-resistant depression, practices must adapt their billing workflows to meet these demands.
To simplify the process and ensure accuracy, mental health providers can consider outsourcing TMS billing to experts like 24/7 Medical Billing Services. Our experienced team understands the complexities of TMS coding, modifiers, and payer-specific requirements—helping providers focus on delivering quality mental health care.

Content Source: [https://www.247medicalbillingservices.com/blog/transcranial-magnetic-stimulation-billing-cpt-90867-90869-with-modifier-updates]

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