Advanced mental health treatments like transcranial magnetic stimulation (TMS) and Spravato (esketamine) change lives, but they also change the billing office’s workload. From pre-treatment authorizations to session-level documentation and claim submission, every step carries its own rules. Even when treatment is clinically appropriate, claims may be delayed or denied if the submitted codes, medical records, provider information, or drug billing pathway do not meet the payer’s requirements.
In 2026, healthcare organizations should review current payer policies before submitting claims for these services. A code’s existence does not automatically mean a payer covers it or reimburses it separately. Coverage depends on the member’s benefit plan, applicable medical policy, provider type, place of service, and claim circumstances.
Understanding TMS Coverage and Prior Authorization
Think of TMS as a way to “wake up” underactive brain regions: a noninvasive treatment that delivers focused magnetic energy through the scalp. Coverage policies commonly address its use for major depressive disorder (MDD), but eligibility requirements differ by payer and plan.
For example, First Coast Service Options’ Medicare local coverage determination (LCD L34522) addresses TMS for adults with MDD in its jurisdiction. The related billing article provides additional coding guidance, including the requirement to report the ordering provider’s name and National Provider Identifier (NPI) on the claim. These requirements should not be assumed to apply identically to every Medicare contractor or commercial payer. First Coast LCD L34522 and Billing Article A57647.
Cigna’s Transcranial Magnetic Stimulation policy EN0383 became effective March 15, 2026. Before starting treatment, providers should review the payer’s latest policy alongside the patient’s individual benefit plan to verify coverage and authorization rules. Read Cigna’s policy. Source: Cigna, EN0383.
Before treatment begins, verify:
- The covered diagnosis and applicable medical-necessity criteria.
- Required previous medication trials, treatment response, or documented intolerance.
- Whether the payer requires prior authorization and how many sessions it will approve.
- Which provider credentials and clinical documentation the payer expects.
- The authorization dates and any limits on repeat or maintenance treatment.
Do not apply one payer’s trial requirements or session limits to another plan. Review the policy version that applies to the date of service.
TMS CPT Codes: What Providers Need to Know
TMS billing relies on a small set of core CPT codes, listed below:
| CPT code | General description |
| 90867 | Initial TMS treatment, including motor-threshold determination and treatment planning |
| 90868 | Subsequent TMS treatment session |
| 90869 | Subsequent treatment involving motor-threshold re-determination and treatment delivery |
Use the code that accurately represents the service performed and follow the applicable CPT guidance, payer policy, and claim-edit requirements. Do not report multiple TMS treatment codes together simply because several activities occurred during a visit.
For example, First Coast’s billing guidance includes code-combination restrictions involving 90867, 90868, and 90869. Review the current First Coast billing article before submitting claims under that jurisdiction.
Common TMS billing errors include selecting the wrong service code, submitting services outside the authorized treatment period, missing ordering-provider details, and failing to document medical necessity. A strong billing workflow checks authorization, clinical records, code selection, and claim fields before submission.
Spravato Billing Codes in 2026
Spravato is a prescription esketamine nasal spray administered in a certified healthcare setting under a restricted Risk Evaluation and Mitigation Strategy (REMS) program. Its billing pathway depends on how the drug is supplied and which payer rules apply.
| Code | General billing consideration |
| G2082 | A bundled code for Spravato, administration, and required observation under applicable Medicare-related coding rules |
| G2083 | A bundled code that covers the higher-dose service, as defined by that code’s descriptor |
| J0013 | Esketamine nasal spray, per 1 mg, effective January 1, 2026; payment and use depend on payer rules |
| J3490 | Unclassified drug code that may be considered only when permitted by the payer and supported by its billing instructions |
Always confirm the current official code descriptor and the payer’s instructions before billing. These codes are not interchangeable, and not every plan accepts all of them, so confirm which ones each payer recognizes before billing. If a payer permits an unclassified drug code, review this guide on HCPCS Code J3490 for unclassified drug billing to understand the documentation and claim details that typically support it.
CMS’s 2026 HCPCS quarterly updates should be checked for current code information. CMS HCPCS Quarterly Update.
Payer-specific instructions can change the correct billing pathway. For example, Highmark’s Spravato reimbursement policy RP-083, version effective March 30, 2026, directs professional providers to use G2082 or G2083 when the professional provider supplies Spravato. When a specialty pharmacy supplies the drug, the pharmacy submits a separate drug claim using J0013. Highmark also instructs professional providers not to unbundle the service by billing J0013 in place of the applicable bundled code. These instructions apply to the plans specified in the policy, not automatically to every insurer. Read Highmark RP-083.
Before submitting a Spravato claim, verify the supplying entity, billing provider, place of service, dosage and units, applicable administration code, and whether the payer requires a bundled or separate drug claim. Check the payer’s current policy rather than relying on an older code reference.
Spravato REMS and Clinical Documentation
Spravato has specific safety and monitoring requirements that affect clinical documentation and billing review. Under the FDA-approved prescribing information, patients must be monitored by a healthcare provider for at least two hours after each treatment, including monitoring of respiratory status with pulse oximetry. The healthcare provider must also assess when the patient is clinically stable and ready to leave the setting. Spravato is available only through the restricted REMS program. FDA prescribing information.
Maintain documentation that supports the service provided, including:
- Applicable diagnosis and medical necessity.
- Prior authorization and approved treatment dates, when required.
- Drug dose and units, administration details, and relevant records.
- Required monitoring and observation documentation.
- Provider and facility participation in the applicable REMS requirements.
- Records supporting the selected billing pathway and any separate drug claim.
Billing teams should not assume that a claim is compliant simply because the authorization was approved. Clinical records must support the services and units submitted.
Common TMS and Spravato Claim Denials
| Denial issue | Recommended action |
| Missing or expired authorization | Confirm authorization dates, approved services, and session limits. |
| Insufficient medical-necessity documentation | Check that records address the payer’s current criteria. |
| Incorrect code or billing pathway | Verify the code descriptor and payer-specific billing instructions. |
| Drug units or dosage do not match the record | Reconcile the claim against the medication administration documentation. |
| Missing ordering-provider information | Review required claim fields and provider identifiers. |
| Incomplete observation records | Confirm that required Spravato monitoring is documented. |
| Outdated policy reference | Recheck the policy version applicable to the date of service. |
A corrected claim is appropriate when the provider submitted inaccurate or incomplete claim information and the payer permits correction. An appeal is generally appropriate when the provider disputes the payer’s denial and can support the original submission with policy provisions and relevant documentation. Follow the payer’s deadlines and submission procedures.
Pre-Submission Checklist
Before sending a TMS or Spravato claim, confirm that:
- The patient’s eligibility and benefit coverage have been checked.
- The current payer policy and authorization requirements have been reviewed.
- The diagnosis and medical records support medical necessity.
- The CPT or HCPCS code accurately reflects the service and drug supply arrangement.
- The dosage, units, provider identifiers, and dates are consistent.
- Required observation and REMS documentation is complete for Spravato.
- The claim follows applicable code-combination, bundling, and submission rules.
How Revantage Healthcare Business Solutions Can Help
Revantage Healthcare Business Solutions supports healthcare organizations with medical billing, eligibility and benefits verification, prior authorization, and revenue cycle management. For practices providing TMS or Spravato, a structured billing workflow can help identify documentation gaps, verify payer requirements, and address preventable claim errors. Learn more about our Medical Billing Services and explore support for Prior Authorization Services.
Frequently Asked Questions
Which CPT codes are used for TMS billing?
The primary TMS codes include 90867 for the initial treatment, 90868 for subsequent treatment, and 90869 for subsequent treatment involving motor-threshold re-determination. Confirm current code guidance and payer-specific restrictions before billing.
Is J0013 the correct code for every Spravato claim in 2026?
No. J0013 describes esketamine nasal spray per 1 mg, but whether it is appropriate depends on the payer, drug supply arrangement, and billing instructions. Some policies require a bundled code for professional-provider-supplied treatment.
Does Spravato require two hours of monitoring?
The FDA-approved prescribing information requires healthcare-provider monitoring for at least two hours after each treatment, including respiratory monitoring with pulse oximetry. Required documentation should be maintained in accordance with the applicable clinical and payer requirements.
What should a practice do after a TMS or Spravato denial?
Identify the specific denial reason, compare the claim with the applicable payer policy, and review authorization, coding, and supporting documentation. Correct the claim when claim data need correction, or submit an appeal when disputing the payer’s decision.
Conclusion
Successful TMS and Spravato billing requires more than selecting a procedure or drug code. Practices need to verify current payer policies, confirm authorization, document medical necessity, follow the correct drug billing pathway, and maintain required monitoring records. Because coverage and reimbursement rules differ, confirm the requirements that apply to each patient and date of service before submitting a claim.
Disclaimer: This article is for general educational purposes and is not a guarantee of coverage or payment. Payer policies, benefit documents, coding guidance, and federal requirements may change. Verify the current official guidance before billing.
