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How to Prevent TMS Claim Denials in 2022

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    Transcranial Magnetic Stimulation Therapy Reimbursement in 2022

    Transcranial Magnetic Stimulation (TMS) can be a lifeline for patients, but a headache for billing

    Transcranial Magnetic Stimulation, or TMS uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. For some patients with severe depression, TMS can provide relief when other treatments fail. 

    On the back end though, getting TMS treatment covered by insurance can be a headache. Bad TMS billing and coding habits can lead to downstream ‘symptoms’ that impact revenue.   The good news is that billing for TMS therapy doesn’t have to be a headache.  Having a team knowledgeable in TMS services and billing patterns can ease billing challenges. 

    One common challenge: TMS claims are often denied. The key to preventing TMS denials is to understand why the claims are being denied.

    TMS reimbursement can be a tedious and difficult process if you do not have experience in it and could lead to claim denials. The most important aspect of it is having all the required documentation to prevent getting rejected. According to the CMS, these are the documentation requirements: 

    The patient’s medical record should include but is not limited to:

    • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
    • Relevant medical history
    • Results of pertinent tests/procedures
    • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

    What Will Cause a Claim to Be Rejected or Denied?

    Specific TMS claim denial codes vary between different insurance companies. But when a TMS claim is denied, it is often for one of three reasons: the procedure is considered experimental or investigational, the claim had a missing or invalid prior authorization, or TMS is considered a non-covered service.

    1. The Procedure Can be Considered Experimental or Investigational

    TMS is an FDA-approved treatment for Major Depressive Disorder. It is also being explored as a promising treatment for other conditions, such as anxiety or PTSD. For those conditions, however, TMS is considered experimental or investigational by the FDA. Due to this, it is important the proper diagnosis codes are listed on the claim. Sequencing is equally important when reporting more than one diagnosis code. 

    Often, patients present with both depression and anxiety or depression and PTSD. In these cases, it is important to make it clear in billing and in the documentation that the primary reason for the TMS therapy is for Major Depressive Disorder, rather than another condition. This can be done by listing the diagnosis code for Major Depressive Disorder first on the claim.  Any behavioral or non-behavioral conditions that have no bearing on the treatment plan should not be reported on the claim.  

    Some doctors may decide that a patient requires TMS for conditions considered to be experimental. In those cases, some doctors bill patients separately; others may decide to provide them for free.

    2. Missing or Invalid Prior Authorization

    For many treatments, physicians need to get prior authorization from the insurance company to confirm that the treatment is medically necessary. TMS is not unique in that regard, but prior authorizations for TMS can be especially easy to overlook. 

    That’s because some patients have separate plans for medical health insurance and behavioral health insurance. TMS is billed to the behavioral health plan. The behavioral health plans may require prior authorization for TMS even though medical plans typically do not.

    Forgetting the prior authorization likely means a TMS claim will be denied. Services provided on an emergency basis should be documented and can be used to support retro-authorization requests. A best practice is to check for prior authorizations before claims go out and include the authorization number on all claims. 

    3. Non-Covered Service

    Finally, the most bewildering denial of all: a patient received TMS for depression, not anxiety or PTSD, and the prior authorization was included. But the claim was still denied as a “non-covered service.” What could have happened? 

    This is where the devil is in the details. TMS is approved by the FDA as a medically necessary treatment for Major Depressive Disorder; it is not approved for other kinds of depression. 

    A medical coder who doesn’t understand this nuance may code a different diagnosis, such as depression, unspecified depression, or unspecified depressive disorder, instead of Major Depressive Disorder. In addition, if a patient has more than one related diagnosis, Major Depressive Disorder likely needs to be listed as the first diagnosis.  

    In addition to the coding, documentation is also important. The diagnosis of Major Depressive Disorder should be easily confirmed through thorough documentation of how the patient presents. If the documentation doesn’t back up the diagnosis, a claim may still be denied.

    Having a skilled coder that is familiar with TMS billing, medical terminology and interpreting documentation is critical when securing payment for services rendered. 

    Avoiding TMS claims denials is possible, it just requires savvy billing. The good news, which TMS affirms, is that our brains are flexible. Just like patients can re-train their brains, back-office teams can re-train habits to avoid TMS claim denials and claim denials in general. A back-office solution like Gentem can help make sure no claims slip through the cracks. 

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    How to Handle a Denied Claim?

    If your health insurance company refuses to pay your claim or terminates your coverage, you have the right to appeal the decision and have a third party consider it. 

    Don’t worry if you do not know how to appeal a TMS claim denial, it can start with asking the insurance company to reconsider their decision. The insurance company must tell you why they rejected your claim and ended your indemnity.

    The process to appeal should not be too complicated, it consists of 2 general steps:

    Internal Appeal

    You have the legal right to have the insurance company reconsider your claim. This is called an internal appeal. All you really need to do is find out why your claim was rejected, ask your doctor for help, and send the information your insurance company needs to process the claim correctly.

    External Appeal

    If, after your internal appeal, your insurance company still denies your claim, you can ask an independent organization to investigate. This is usually the federal insurance supervisory authority. The internal appeal should help explain how to begin this process.

    External appeals may contain new information for your defense, so please contact your doctor again to let him know what is happening. There may be additional information  to include.

    Gentem can make this process so much easier by managing the claims denial process for you.

    Using a combination of world-class automation and experts, we ensure clean claim submission that minimizes claim denials and appeals. Our team follows up on every single claim until you get paid.

    This article was written by a member of the Gentem Health Revenue Cycle & Billing Team

    Voncil Webb

    Voncil Webb

    Revenue Cycle Manager

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