Billing and Coding for TMS Therapy by FCbilling

Transcranial Magnetic Stimulation or TMS therapy is widely used by Physiatrists to treat certain types of Major Depressive Disorder in adult patients. While it is the provider’s responsibility to determine whether a patient may benefit from TMS treatment, it is the job of the biller to process all paperworkfor pre and post visit follow-upfor TMS therapy. The secret to successful claim payment is in the detailedwork done by the billing department.

Insurance for TMS Therapy

Medicaid Insurance

Pre-certification of insurances coverage for TMS therapy is a must. Most insurances with mental health benefits will cover TMS therapy when deemed necessary. One major exception is Medicaid. Billers need to check with local Medicaid providers for TMS coverage verification. Patient’s previous medical records need to indicate all methods of treatment done for the condition and how TMS therapy will improve the depressive disorder.

Biller will need to have the doctor review and approve all related exam notes and medical records before submitting to insurance. In certain instances, the medical director of the insurance company might contact the provider directly for more information. Once approved by insurance, the patient must sign a consent to receive TMS treatment. TMS treatment therapy is done over 4 – 6 weeks period, with 20-36 sessions. Our suggestion is to get approval for at least 3 months to cover any missed or delayed appointments.

Coding for TMS Treatment

CPT 90867 will be billed for the first TMS treatment and CPT 90868 will be billed for subsequent TMS encounters. For certain patients, doctor might need to do a re-determination of the Motor Threshold (MT); in that case, it is appropriate to bill CPT 90869. The claim form will have TMS CPT codes and supporting diagnosis. If the provider is only doing the therapy in a session, no modifier is needed for coding the TMS service.

It is very important to check with all participating insurances if TMS is a covered benefit under the provider’s contract. If not, the biller must make a formal application to add TMS CPT codes to the contract and obtain a copy of the updated contract before treatment begins. If the provider deems TMS reimbursement rate to be low for any insurance, formal application for fee negotiation for TMS therapy can be submitted. Always obtain a copy of all insurance Fee schedules to keep on file in order to make sure the provider is getting reimbursed according to the contract.

Modifiers for TMS Billing

Modifiers play an important role in TMS billing by providing additional information that helps to accurately describe the services rendered. “Modifier 25” might be used, although rarely, to indicate a separately identifiable evaluation and management (E/M) service was provided on the same day as the TMS therapy session. It helps to distinguish the E/M service from the TMS therapy itself, ensuring proper reimbursement for both. Another modifier used in TMS billing is the “modifier 59,” which might be utilized sometimes to identify distinct procedural services performed during the same session or on the same day. This modifier is helpful when multiple TMS therapy sessions or different types of TMS therapies are provided concurrently.

Proper use of modifiers in TMS billing ensures accurate coding, appropriate reimbursement, and adherence to billing regulations and guidelines. It is essential for TMS therapy providers to stay updated on the latest coding guidelines and consult with payers to ensure the correct application of modifiers for accurate billing.

Billing for TMS Therapy

Billing for TMS therapy begins with gathering essential documentation, such as patient intake forms, consent forms, and diagnosis/treatment plans. Accurate and complete patient information is crucial for proper TMS billing. It is important to verify insurance coverage and obtain necessary authorizations or pre-certifications before initiating TMS therapy. Proper coding is essential, utilizing the appropriate CPT codes for TMS therapy services. Timely and accurate documentation of each therapy session, including progress notes and treatment logs, is necessary to support the medical necessity of the treatment.

The billing process typically involves submitting claims to insurance companies, abiding by their specific guidelines and requirements. Regular follow-up and communication with insurances can help resolve most billing issues or claim denials. Overall, efficient and accurate billing practices ensure that TMS therapy providers can receive contracted reimbursement for the valuable services they offer.

Avoiding Billing Errors for TMS Therapy

Effective billing is the key to account success for Transcranial Magnetic Stimulation (TMS) providers. However, like any billing process, TMS billing is prone to errors which can lead to administrative hassles, payment delays, and financial loss. One common TMS billing error is incorrect coding, where the wrong codes are used for procedures or services provided. This can result in denied claims and delays in payment. To avoid this, it is essential to stay updated with the latest coding guidelines and regularly train staff on proper coding practices.

Another error is insufficient documentation, where essential details are missing or incomplete. It is crucial to ensure comprehensive documentation of patient information, treatment plans, and progress notes to support the billed services. Additionally, failing to verify insurance coverage for TMS therapy or neglecting to follow up on outstanding claims can lead to missed reimbursements. Implementing a robust system for insurance verification for TMS treatment and diligently tracking claims can help avoid such errors. By proactively addressing these common TMS billing errors, providers can streamline their billing processes, minimize financial risks, and ensure optimal reimbursement.

Documentation for TMS Billing

For TMS therapy billing, several essential documents are necessary to ensure accurate and efficient billing process. First and foremost, a completed patient intake form is required. This form gathers important demographic and insurance information from patients, including their names, contact details, insurance provider, and policy number. Additionally, a signed consent form is crucial, which outlines the patient’s agreement to receive TMS therapy and acknowledges their understanding of the procedure, potential risks, and benefits. Furthermore, it is vital to maintain documentation of the patient’s diagnosis and treatment plan, typically provided by the referring physician or psychiatrist.

This information helps establish medical necessity for TMS therapy. Finally, progress notes and treatment logs should be maintained throughout the course of the therapy, documenting each session, the duration, and any significant observations or changes in the patient’s condition. By ensuring the availability and accuracy of these documents, TMS therapy billing can be done properly, facilitating reimbursement and ensuring compliance with insurance requirements and regulatory guidelines.

Estimate reimbursements for TMS Therapy

Estimated Reimbursements for TMS Therapy:

TMS CPT CodeTricareCommercial Insurance
90867$400$300
90868$250-300$170-250
90869$350-400$250-300

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Success in Billing for TMS Therapy

Successful TMS billing is crucial for ensuring the efficient and accurate reimbursement of TMS therapy services. It requires thorough documentation, including patient intake forms, consent forms, and diagnosis/treatment plans, to support the medical necessity of the treatment. Proper coding and adherence to insurance guidelines are essential to avoid TMS claim denials and delays in reimbursement. Timely and accurate documentation of each TMS therapy session, along with progress notes and treatment logs, helps provide a comprehensive overview of the treatment course.

Regular communication and follow-up with insurance providers can help resolve any billing issues that may arise. By implementing these practices, TMS therapy providers can navigate the billing process effectively, ensuring transparent financial transactions and facilitating access to this valuable therapeutic modality for patients in need.

If your practice is having difficulty in getting payment for TMS therapy or having any other Behavioral Health claim payment issues, please feel free to contact FCbilling (myfcbilling.com) so that we can assist you in navigating through the insurance maze.

You can also read: 4 Common Billing Challenges for TMS Therapy

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