Billing for TMS Therapy: Top Three Things to Know in 2021

Three common TMS billing challenges and how to avoid them.

Transcranial Magnetic Stimulation (TMS) is an FDA-approved treatment option for Major Depressive Disorder. When our brains get in ruts, thinking differently takes practice; TMS helps the brain practice new reactions. 

Just like thinking differently requires practice, billing for TMS services also requires practice. Dr. Khaled Bowarshi, a board certified psychiatrist, who offers TMS services in Florida’s Tampa Bay Area was having more TMS claims denied than he would have liked. 

“Every dollar counts when it comes to billing,” Dr. Bowarshi said. That’s especially true for his practice, which offers some TMS services that insurance won’t cover–for free. That commitment makes getting billable claims paid even more important.

Billing for TMS can be complicated, but it is possible to get it right. When Dr. Bowarshi’s practice switched to Gentem, his practice saw a 15% increase in revenue. “Fifteen percent is nothing to sneeze at!” he said. 

What changed? Dr. Bowarshi noticed the little things: prior authorization numbers on every claim, consistent billing for extra services, and bills submitted the same day as the treatment. ”I think those small things are what make that 15% difference,” Dr. Bowarshi said. 

In TMS billing, it turns out, the small things do make a big difference. That’s why Gentem uses data analytics to flag potential billing issues early, before they turn into denied claims. 

In fact, by looking at the data across a number of practices, we’ve been able to identify common challenges when billing for TMS–as well as easy steps that can help claims get paid.

1. TMS Billing is Complicated. Create a Consistent Protocol.

Part of why billing for TMS can be challenging is simply because TMS therapy requires so many steps. First, TMS requires extensive pre-work to ensure that the treatment is medically necessary. Then, the therapy itself requires a number of sessions on a strict schedule. Finally, most patients require additional psychotherapy appointments or other means of support between TMS sessions.

With a scattershot approach, some billable services are bound to slip through the cracks. Instead, the gold standard is for your practice to have a clear protocol for when services will be provided. Therapy, calls, and medication management happening in between sessions should all be included in the protocol.

Once there is a plan in place, billing should review and make sure everyone is on the same page about which services can be billed and what documentation will be needed for each. All TMS services are covered, as long as you are actively documenting them. Here are the CPT codes you should have at your fingertips:

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 ensure that patients get the best care.

Most insurance providers will only pay for TMS if it is medically necessary, meaning the patient has exhausted their other therapy options. Authorization requests should clearly document a Major Depressive Disorder diagnosis and that other treatment options have been unsuccessful. 

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 a first appointment, it’s a good idea to ask patients to bring relevant records from past providers if they can.

Insurance providers may also require reauthorizations if patients miss too many sessions. TMS requires a number of treatment schedules on a strict schedule. If patients wait too long between sessions, insurance providers may require a reauthorization process. Make sure patients understand the consequences of missing sessions or rescheduling too often.

3. Each Provider Is Different. Make Billing Your Partner.

Whether you are going for authorization of 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 for the front office, noting any red flags and clearing the road to get reimbursements. In particular, 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 create a clear 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 authorization requests are submitted, not after. In the best case, you can get an authorization within 72 hours. If information is missing, authorizations can get stuck in limbo.

Gentem’s dashboard and tools make it easy to spot missing or incorrect information ahead of time. That, of course, means more revenue for practices like Dr. Bowarshi’s. “This solved my problem,” Dr. Bowarshi said. “I don’t worry any more about billing.”

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