TMS Therapy and How to Implement It

TMS is a non-invasive technique that is recommended to patients suffering from major depressive disorder after all other treatment plans have failed. Not all payers cover it, and for Medicare and others that cover it, some specific conditions must be met before it can be billed. To get the details, read along!

TMS is an abbreviation for transcranial magnetic stimulation, which is a form of treatment for severe depression. The treatment involves the use of a device to generate electromagnetic fields around the patient’s head to reduce their symptoms of depression. Typically, TMS treatment sessions last for about 45 minutes, and to achieve any clinical efficacy, a total of 20 to 30 sessions is required. Since the coil is placed against the patient's head near their forehead, the procedure is non-invasive and requires no anesthesia or radiation used.

Certain regulations and guidelines specified by  Medicare must be followed when providing TMS therapy. (Check the local policy of your Medicare Contractor.)

These are the key points:

• To establish a medical necessity for the therapy, the patient has to be diagnosed with a major depressive disorder, and the diagnosis has to be properly documented in medical records.
• There must be a proven ineffectiveness of previously taken drugs or failed psychotherapy sessions. The patient has a history of taking antidepressants that have shown no clinical effectiveness. In essence, TMS therapy can’t be prescribed by the provider without first exhausting other types of treatment or therapy.
• The patient has to be 18 years or older as TMS therapy is not approved on children by the FDA.
• There is a need for continuous daily treatment for clinical improvement.
• Diagnosis codes for reporting TMS therapy are ICD-10 CM codes F32.2 “Major depressive disorder, single episode, severe without psychotic features” and F33.2 “Major depressive disorder, recurrent severe without psychotic features”.

Limitations may differ. Check your payer's policies.

The limitations of the TMS therapy

These are basic precautions that must be taken when planning any treatment with an electromagnetic coil. The precautions include the presence of metal implants in the patient’s head and various pre-existing conditions, such as alcoholism and cardiovascular diseases.

The provider-specific perspective of the treatment

The first and foremost rule is that only a qualified psychiatrist, is allowed to prescribe TMS.  

The therapy itself has to be administered by the prescribing physician or, in some cases, a clinical staff, such as a technician (under direct supervision). But the physician is expected to conduct the initial determination of the motor threshold (CPT code 90867) and identify the appropriate coil location for subsequent treatments. Then, subsequent motor threshold determinations may be delegated by the attending physician to another, appropriately qualified physician, or to a member of the clinical staff (CPT code 90869).

In later sessions, the qualified physician must be available on-site to review the clinical course of each daily treatment session to determine whether to make any modifications to the subsequent daily treatment. The qualified physician is expected to provide appropriate documentation that supports the medical reasons for the therapy, and such documentation should be made available upon request.

Of course, payers’ documentation guidelines may seem a bit too complicated, but it is extremely important to strictly follow them. WCH Service Bureau can help you in this regard — we provide qualified internal auditing services to our clients. Carefully reviewing your medical records from time to time is very important to avoid potential Medicare audits, and our specialists can certainly help you with that!

How should the TMS therapy be billed and reported?

CPT codes for TMS therapy are the following:

• 90867: stands for initial motor threshold determination, including delivery and management
• 90868: used for a subsequent session
• 90869: used for a subsequent determination

An important question to ask before performing the service is whether it is covered by patient’s insurance or not. TMS therapy is covered by Medicare, but the provider must be eligible to perform the service, the patient must have active Medicare Part B on the date of service, the equipment used during the session must be FDA-approved, and the service must be medically necessary.

Medicare’s policies indicate that there will likely be cost-sharing with the patient. However, Medicare Advantage plans may offer additional benefits.

Commercial plans, such as United Healthcare, Cigna, Aetna, BCBS, Tricare, Beacon Health, and others, cover TMS in accordance with the patients' policy. However, neither NY Medicaid nor Medicaid plans cover TMS therapy, and the patient cannot be billed for such services without prior written approval. The only NY Medicaid plan which currently covers TMS is HealthFirst Managed Medicaid.

 And, this brings us to the issue of eligibility. Properly checking your patient’s coverage is key to ensuring proper payment for your services. Some commercial policies may not cover TMS therapy, so it is crucial to double-check the eligibility prior to rendering the service. And in this regard, we’re happy to help you! WCH Service Bureau has a unique eligibility tool for our clients. Basically, it is a website where you can check the policies of different plans without having to call the insurance company or register for a separate provider portal.

Sign up today and start checking your patients for just 0.17c per transaction!

Furthermore, commercial payers may require prior authorization before the therapy, and services performed without approval are subject to denial.

To learn more about TMS, Get our Webinar recording where we covered:

• Overview of TMS therapy.
• When it should and should not be used? 
• Who can administer TMS? Look into supervision requirements. 
• Is TMS really worth the investment?  
• How to bill TMS to Insurance? 
• Examine TMS coverage by Medicare and commercial payers.
• Review of authorization requirements by payers.