Use of Spravato has emerged as a promising treatment for patients with treatment-resistant depression, offering hope where traditional therapies have failed. But billing for this innovative therapy can be a difficult task.
I will discuss 7 common billing challenges associated with Spravato therapy, along with actionable strategies to help providers streamline the billing process and ensure timely payment for this critical service.
1. Complexity of Spravato Billing Codes
One of the primary challenges in Spravato billing is choosing appropriate CPT (Current Procedural Terminology) and ICD-10 codes for documentation. Incorrect coding can lead to claim denials, delayed payments, or underpayments.
Observation and monitoring for Spravato treatment in the physician’s office is reported using Evaluation and Management codes, 99202-99205 and 99212-99215. Providers will often code 99215, based on the total time spent for observation.
In addition, prolonged observation is indicated on the claim using CPT codes 99417 for most insurances and G2212 for Medicare or Medicare-related plans. Units used for prolonged services will depend on how much time is spent beyond 54 minutes.
Providers who choose to do Buy-and-Bill for Spravato treatment will use a different set of codes for billing, making the Spravato procurement model an important billing consideration.
For Medicare, G codes are used for drug administration with observation: G2082 for up to 56mg and G2083 for over 56mg.
For non-Medicare payers, CMS has designated CPT code S0013 for Spravato (EsKetamine), nasal spray, 1 mg. Total number of units will be reported as 28, 56, or 84. Units are divided into 1mg increments.
Covered diagnosis for Spravato treatment will depend on the payors, so Spravato billing & coding must align with payer policies and LCDs.
The following are some ICD-10 diagnoses to consider
- F32.0 Major depressive disorder, single episode, mild
- F32.1 Major depressive disorder, single episode, moderate
- F32.2 Major depressive disorder, single episode, severe without psychotic features
- F32.9 Major depressive disorder, single episode, unspecified
- F33.0 Major depressive disorder, recurrent, mild
- F33.1 Major depressive disorder, recurrent, moderate
- F33.2 Major depressive disorder, recurrent, severe without psychotic features
- F33.9 Major depressive disorder, recurrent, unspecified
- F32.4 Major depressive disorder, single episode, in partial remission
- F32.5 Major depressive disorder, single episode, in full remission
- F33.40 Major depressive disorder, recurrent, in remission, unspecified
- F33.41 Major depressive disorder, recurrent, in partial remission
- F33.42 Major depressive disorder, recurrent, in full remission
Be aware of payer policies and LCDs before submitting claims, as incorrect codes may result in payment error or delay.
2. Insurance Authorization and Pre-Approval Challenges
Insurance authorization is one of the most significant hurdles in Spravato billing. Since Spravato is a relatively new and high-cost medication, insurers require prior authorization or pre-certification before they approve coverage. The pre-approval process can be time-consuming, and not obtaining the necessary approval can result in high balances for patients.
To avoid delays, denials, and incorrect reimbursements, ensure all required documentation is provided to the insurance company.
This typically includes
- A detailed clinical history showing previous treatments have failed.
- Documentation of diagnosis, including symptoms, medical history, and all previous therapies.
- The physician’s statement confirms the necessity of the Spravato treatment.
If authorization is denied, it may be necessary to appeal the decision.
3. Cost and Insurance Coverage Variations
Spravato is a costly medication, and insurance coverage varies by payer. While some insurances may cover Spravato, others may not, or some may have strict requirements for coverage. This creates uncertainty for patients, healthcare providers, and medical billers.
Each insurance payer has its own set of policies regarding coverage for Spravato, and it is crucial to understand these policies before starting treatment. Some plans may require patients to try other antidepressants before Spravato can be approved, while others may limit the number of treatments covered per year.
It’s essential to contact insurance to confirm coverage before administering Spravato. If the insurance requires co-pays or deductibles, these should be communicated clearly to the patient prior to treatment to avoid surprise billing.
4. Complexity of Billing for Spravato Treatment
Regulations require healthcare professionals to be present to administer the medication and monitor patients, making REMS compliance mandatory. These services must be properly billed using appropriate procedure codes, such as the administration and observation codes mentioned earlier.
A separate charge is applicable for monitoring time, and some payers may even have specific codes associated with the administration of Spravato. Coding details have been discussed above.
Outpatient facility codes differ from in-patient service codes. You will need to check each payer’s requirements before submitting claims. If you choose to do buy-and-bill, be sure to use the proper bundled code for Medicare claims. Medical billers will need to ensure all required codes are documented and billing aligns with payer policies to avoid delays in reimbursement.
5. Denials and Appeal Process for Spravato Claims
Claim denials for Spravato billing are common, and understanding how to manage them is crucial. Common reasons for denials include lack of prior authorization, incorrect CPT or ICD-10 codes, insufficient evidence of medical necessity, and exceeding annual treatment limits set by insurance companies. Being aware of these issues can help minimize denials and ensure proper reimbursement.
When a claim is denied, carefully review the remark codes for the explanation of denial and take action accordingly. If insurance requires additional documentation to support treatment, submit all supporting documentation promptly. This may involve submitting more detailed medical notes or a letter from the treating physician to demonstrate the medical necessity for Spravato therapy.
6. Make Patient Education a Priority
Since Spravato is a high-cost treatment, patient financial responsibility can be a significant factor. The cost of Spravato can vary depending on insurance coverage, and some patients may face high out-of-pocket costs, including co-pays or deductibles.
Providers will need to communicate clearly with patients regarding their financial responsibility. Patients should be made aware of the potential costs before treatment begins and agree to pay the amount at the time of treatment. Transparency can prevent confusion and help avoid payment disputes later.
7. Staying Current with Spravato Billing Regulations
Spravato billing regulations are still evolving as the medication becomes more widely used. Insurers may change their policies, new codes may be introduced, and new regulations may be implemented. Physicians and billers need to stay updated on these changes to ensure compliance and avoid claim rejections.
Strong communication with insurance can help you stay informed about the latest changes in Spravato billing. Additionally, subscribing to updates from organizations such as the American Medical Billing Association (AMBA) and regularly checking payer policy updates can help you keep abreast of the latest developments.
Conclusion
Spravato billing presents unique challenges, but with adequate knowledge, preparation, and follow-up, healthcare providers and medical billers can navigate these challenges successfully. By understanding billing rules for these services, keeping abreast of changes in requirements, and clear communication with patients, providers can ensure proper reimbursement for Spravato treatments.
If you’re facing challenges with Spravato billing, our specialized Spravato billing solutions can ensure accurate claims and timely reimbursement. Contact us today!
