Billing Challenges for TMS Therapy-FI

As physicians incorporate more innovative treatments for their patients, billers will need to keep pace with new technology in order to successfully bill for these new services. Many Mental Health physicians are using Transcranial Magnetic Stimulation, or TMS therapy, to treat symptoms of depression. TMS therapy is used when other treatments have failed to improve patient’s condition. If you are billing TMS therapy for the first time, I suggest reading through all literature provided by the manufacturer to gain a good understanding of this very effective treatment for depression. Billers should have a good understanding of how TMS therapy works and under which circumstances doctors choose to offer this therapy to patients. In this article, we will focus on some billing challenges for TMS Therapy.

TMS therapy is a high-value, life-changing procedure requiring an in-depth Mental Health billing knowledge in order to submit clean claims for reimbursement. To avoid claim processing frustration, study the procedure, treatment method, indication for treatment, and insurance requirement for delivering TMS therapy to patients. I will discuss four top challenges in billing TMS therapy.

What is TMS Therapy?

Transcranial magnetic stimulation (TMS) works to stimulate underactive nerve cells in the brain using magnetic fields. TMS therapy is done with an FDA-approved machine that sends magnetic energy pulses through the prefrontal cortex. As a result, TMS is able to painlessly revitalize areas of the brain responsible for mood control and improve communication within the central nervous system.

An electromagnetic coil, about the size of a hand, is held against the front part of the scalp over an area of the brain involved in mood regulation and depression. Short electromagnetic pulses are administered through the coil. The magnetic pulses cause small electrical currents that stimulate nerve cells in the targeted region of the brain; they are about the same strength as a magnetic resonance imaging (MRI) scan. Trials have shown lasting, positive effects on brain functions in those who have otherwise experienced a treatment-resistant form of depression. (Source: tmstherapy.org)

CPT Codes for TMS Therapy

If your medical practice is offering TMS therapy, you will need to know the group of CPT codes needed to represent each treatment. You will also need to identify insurances your provider is contracted with for billing TMS therapy. Download copies of each insurance policy for providing and billing TMS.

  • CPT Code 90867 – Transcranial Magnetic Stimulation by Physician or Qualified Health Care Professional, in Office Setting
  • CPT Code 90868 – TMS Treatment After Initial Assessment (30 – 34 sessions)
  • CPT Code 90869 – Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management, Remapping.

Disorders treated with TMS Therapy

Primary diagnosis (ICD-10 codes) currently approved by insurances are:

  • F32.2 – Major depressive disorder, single episode, severe without psychotic features
  • F33.2 – Major depressive disorder, recurrent severe without psychotic features
  • If your TMS claim does not have one of these diagnosis code as primary code, your claim will most probably be denied as an experimental procedure.

How to Get Started with TMS Therapy

How to Get Started with TMS Therapy

First step is for the patient to speak with his/her mental health provider. Doctor’s office needs to establish good communication with their patients, insurances, and TMS representative. Once the need is established, doctor will have the medical staff work with insurance to get all pre-work done and obtain authorization for the therapy. Office will contact patient to give information on how this therapy is done and what to expect from the treatments. TMS therapist will need to encourage patients to take time and read through all the materials and take note on any questions or concerns to discuss with their doctor before receiving treatment.

4 Common Billing Challenges for TMS Therapy That Psychiatry Practices Face 

Billing Challenges for TMS Therapy

1. Understanding Insurance Requirements

Before your practice offers TMS therapy, you will need to decide which insurances you will contract with for providing TMS. Just because a doctor is in-network with insurance, does not automatically include TMS therapy treatment in the contract. Take some time to verify contract coverage.

If provider feels that reimbursement rate for TMS is acceptable, fill out the necessary forms to request contract extension to include TMS therapy. Keep a copy of the updated and signed contract on file. Also, keep a copy of the fee schedule on file and check each year for any reimbursement changes. You will need to read through, understand, and keep a note of all insurance pre-requirements, guidelines for documentation, limitation for service frequency, number of allowed sessions, and authorization expiration date.

2. Establishing Need for TMS Therapy

As in the case of most high value medical services, doctors will need to demonstrate the need for TMS therapy for a patient in order to receive insurance authorization to render treatment.

One major factor insurance look for is the establishment of need. Doctors will need to make detailed exam notes of all treatment methods tried to lessen the symptoms of depression. Insurances will look to see which treatment methods have been tried and their outcome. Patient’s medical records will establish the need for the TMS therapy in the documentation of failed treatments. Patient’s record might include psychological counseling, medication, psychotherapy, and other methods. Details of each treatment method and its outcome need to be clearly documented.

3. Obtaining Authorization for TMS Therapy

When submitting request for TMS therapy prior authorization, include all treatment records. Attach all records in order of service date. Make it as easy as possible for pre-authorization department to review your request. If necessary, include a forwarding letter from the provider stating the need for the treatment.  Well-prepared and well-presented documentation leads to successful outcome. Be sure to keep detailed notes in patient’s file of what has been submitted to insurance. This will make it easier to do follow-up with insurance as well as patient.

If request for treatment is rejected by insurance after you have followed all protocols, request a peer-to-peer review. Always keep patient informed. Having patient work with the practice to obtain authorization helps speed up the process.

It is important to keep detailed notes of all correspondence with insurances. Note the time of call, call reference number, representative name, and a summary of the conversation. Once you receive the authorization, note the number of visits allocated, treatment details, and expiration date. Inform the patient as soon as you receive the authorization to make appointment for TMS therapy. Document the authorization number on the claim for each session. Following is a sample authorization.

Obtaining Authorization for TMS Therapy

4. Submitting TMS Therapy Claims for Payment

TMS therapy is a high-value procedure requiring prompt payment. Brining in payment with first claim submission is essential for maintaining good patient care and a profitable practice. Billers have to keep current LCD on file for all contracted insurances for TMS therapy. Before submitting claim, ensure all patient and insurance information is correct. Having incorrect patient information will cause a claim denial with remark code “Patient cannot be found”.

If payor ID for insurance is not correct, claim will either be sent to wrong insurance or not transfer over to insurance at all from your clearinghouse. It will stay in the clearinghouse as an Error Claim. If insurance ID is not correct, claim will be rejected by insurance with same remark code, “Patient cannot be found”. Cross-check CPT and diagnosis with the exam notes to be sure correct codes are being billed out. Cross-check diagnosis codes with LCD list to be sure your claim has LCD supported diagnosis. Check all other information on the claim for errors. Submitting clean claim with insurance supported CPT and diagnosis will get your claim paid faster.

If insurance rejects your first submission for any reason, you need to understand the rejection reason and review your submission for any other additional error. It is important to get TMS claim processed before patient’s next session.

FCbilling’s Success with TMS Therapy Claims

FCbilling has extensive experience working with all insurances for TMS therapy. We are in communication with provider relations department and local insurance representatives to keep updated on all changes and regulations for TMS therapy.  Our team verifies insurance coverage, obtain pre-authorization, update fee schedules, and negotiate allowable rates for TMS therapy. We follow-up on any non-pay claims as soon as we receive them. We inform provider for any additional insurance requirements to get claims processed quicker. We do resubmission, appeals, and take any other steps necessary to get TMS claims paid to maintain a successful TMS therapy practice.

Read our most popular article about TMS Therapy Billing & Coding.

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