Transcranial magnetic stimulation (TMS) is an FDA-approved treatment option for major depressive disorder. When our brains get in a rut, thinking differently takes practice; TMS helps the brain practice new reactions.
Like this brain training, billing for TMS services also requires practice. It can be complex and convoluted at times. But understanding different pitfalls — and how to overcome them — can make sure you’re getting paid what you deserve.
Three Common TMS Billing Challenges and How to Avoid Them
Every dollar counts when it comes to billing, which is why it’s critical to get your TMS billing services right. Having a savvy and reliable partner can make that happen.
Here at Gentem, we use data analytics and AI-powered RCM software to flag potential TMS billing issues early, before they turn into denied claims.
After looking at the data across several practices, we’ve identified common challenges when billing for TMS — as well as easy steps that can help you get paid for TMS therapy claims.
1. TMS Billing is Complicated. Create a Consistent Protocol.
Billing for TMS can be challenging because TMS therapy requires so many steps. First, TMS involves extensive pre-work to make sure the treatment is medically necessary. Then, the therapy itself requires several sessions on a strict schedule. Finally, most patients need additional psychotherapy appointments or other support between TMS sessions.
With a scattershot approach, some billable services are bound to slip through the cracks. Instead, your practice should have a defined protocol for when you will provide services. You’ll need to include clear descriptions for all therapy, calls and medication management in the protocol.
Your TMS therapy billing protocol should include:
- Prior authorization numbers for every claim
- Consistent billing for extra services
- Same-day claim submission (submit the day of treatment)
TMS CPT Codes
Once you have a plan in place, billing should review and make sure everyone is on the same page about which services you can bill for and what documentation you need for each. Insurance covers all TMS services, as long as you are documenting them. Here are the CPT codes you should have at your fingertips:
- 90867- (TMS) treatment; initial: including cortical mapping, motor threshold determination, delivery and management.
- 90868 - Subsequent delivery and management: Use this code for repeat sessions; since TMS therapy requires a number of sessions, this is the most common code you will bill.
- 90869 - Subsequent motor threshold redetermination: TMS therapy uses electromagnetic stimulation. Every time the doctor reassesses the amount of stimulation needed, that determination should be billed.
- 90833 - Psychotherapy with evaluation and management: This is the code you will use if psychotherapy is happening during an evaluation and management service.
2. Insurance Will Scrutinize Authorizations. Document Everything.
For many services, insurance authorization can be as quick as the click of a button. Not TMS therapy. Insurance will closely review documentation for authorization requests. They are looking out for their bottom line, but they also want to make sure patients get the best care.
Document Diagnoses and Treatment Options
Most insurance providers will only pay for TMS if it is medically necessary, meaning the patient has exhausted their other therapy options. Your authorization requests should document a major depressive disorder diagnosis and that other treatment options have been unsuccessful.
Document the Prior Authorization Process
It’s also critical that you document steps in your prior authorization process. If you need to appeal a claim, it’s helpful to have as many details as possible.
If you get the authorization online or via payer portal, remember to save a screenshot of the authorization. This can be proof of authorization if you need to appeal a claim denial.
When calling a payer for authorization, make sure you closely document information, including:
- Payer name
- Phone number
- Date and time
- Payer representative name
- Case reference number
Ask Patients for All Relevant Records
Insurance will also want to know that the doctor is looking at the whole patient, considering socioeconomic factors and other long-term conditions. When scheduling the first appointment, ask patients to bring relevant records from past providers if they can.
Avoid Delaying or Rescheduling Treatment
Insurers may also request reauthorizations if patients miss too many sessions or wait too long between sessions. TMS requires several treatments on a strict schedule. Make sure patients understand the consequences of missing sessions or rescheduling too often.
3. Each Provider Is Different. Make Billing Your Partner.
Whether you’re requesting authorization for TMS services or submitting claims, each insurance provider will have slightly different criteria. A strong partnership between physicians and the billing team can keep everything running smoothly.
A good billing team should be the eyes and ears of the front office, noting any red flags and clearing the road to get reimbursements. Billing should be able to make sure the authorization process goes smoothly 100% of the time. To get there, it helps to get all the details right the first time, including an outline of the proposed treatment plan, so that if insurance has questions, you have answers.
Billing teams should also create a checklist to ensure that they have everything they need from the front office for each authorization. Having a clear process will make it easy to catch any mistakes before you submit authorization requests. In the best case, you can get authorization up to 72 hours before a procedure or appointment. If information is missing, authorizations can get stuck in limbo.
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When you put these best practices in place and have a strong relationship with your billing team, you’ll end up with a smooth process for TMS billing. That, of course, means more timely payments and revenue for your practice — allowing you to grow and help more patients live their best lives.
Lean on Gentem for TMS Billing Services and Expertise
Gentem’s dashboard and AI-powered medical billing software make it easy to spot missing or incorrect information ahead of time. Plus, our team of experts has years of experience billing for TMS therapy, so you’ll get paid what you deserve.
Learn more about our state-of-the-art medical billing software and fully-managed RCM services by scheduling a demo today.
Editor’s note: This post was updated on May 3, 2023. It was originally published in May 2021.
