Spravato (esketamine) is the only FDA-approved nasal antidepressant for treatment-resistant depression (TRD) in adults as monotherapy or with an oral antidepressant, and for depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior when used with an oral antidepressant.
Spravato can be acquired through a restricted Risk Evaluation and Mitigation Strategy (REMS) program only due to risks of sedation, dissociation, respiratory depression, and potential for abuse.
Unlike standard behavioral health billing, Spravato requires a deeper understanding of coding rules along with very careful documentation and adherence to regulatory guidelines.
This guide offers clear, actionable information to help you understand the Spravato billing & coding process, save time, minimize denials, and ensure your practice receives proper reimbursement.
Spravato Procurement Method
Spravato can be obtained using two primary models: buy and bill, and assignment of benefits (AOB). The method you choose directly determines which billing codes are allowed and how reimbursement is handled.
- Buy and Bill: With Buy and Bill, your practice purchases Spravato directly from an authorized specialty distributor, stores it onsite, administers it, and bills the payer for both the drug and related services
- Assignment of Benefits (AOB): Under AOB, a specialty pharmacy supplies Spravato and bills the payer for the medication. Your practice bills only for the professional services. This model reduces financial exposure but requires coordination with the specialty pharmacy.
Buy and Bill introduces inventory risk, delayed reimbursement exposure, and potential write-offs if claims deny after administration. AOB models reduce upfront cost but limit billing flexibility. Clinics must evaluate days in accounts receivable, denial reversal rates, and payer reliability when choosing a procurement method. Practices offering Spravato without financial modeling often underestimate cash flow strain.
Insurance Coverage for Spravato
Insurance coverage for Spravato varies significantly between payers and benefit designs. Spravato can be covered by medical or pharmacy benefit (or both), and coverage depends on the local area and patient benefit design. Before starting treatment, verify these critical elements:
- Type of insurance (Medicare, Medicaid, commercial)
- Whether your practice is in-network
- Medical vs. pharmacy benefit coverage
- Behavioral health organization (BHO) carve-out arrangements
- Prior authorization requirements
- Site of care restrictions
Ensure your office collects the appropriate information from the patient’s medical benefit card and separate pharmacy benefit card, if applicable.
Medicare Coverage
Medicare covers Spravato under specific conditions. The program requires the use of bundled G codes that incorporate both the drug and professional services. These codes are required for billing Medicare on both physician office (CMS-1500) and hospital outpatient (CMS-1450) claims.
Medicare patients must meet FDA-approved indications. Medicare Administrative Contractors (MACs) and state Medicaid administrations determine whether a drug, device, procedure, or other service meets all program requirements for coverage.
For Medicare claims using specialty pharmacy procurement, you report only the service codes. When you purchase and bill the product directly, you must use the G codes.
Medicare Advantage plans may handle coverage differently. These plans may choose to cover the product through a different benefit design. Confirm the plan’s preferred benefit and the appropriate product and E/M codes that would be used.
Private Insurance Coverage
Commercial payers have varied policies for Spravato coverage. There are two main coverage pathways:
- Medical Benefit Coverage: Medical benefit provides coverage for provider-administered medications, medications administered in outpatient settings, or medications that are self-administered in a healthcare provider’s office.
- Pharmacy Benefit Coverage: Pharmacy benefit provides coverage for prescription drugs and self-administered medications.
Key verification steps include:
- Confirming which benefit covers Spravato
- Identifying approved sites of care
- Checking for BHO management of behavioral health services
- Verifying your practice’s network status with both the payer and BHO
- Ensuring contracted codes include all necessary drug and service codes
Note: If you receive a denial through either benefit, confirm that the alternate benefit was tried and consider sending a Letter of Medical Necessity to support the request.
Pre-Authorization Requirements for Spravato
Prior authorization (PA) is common for Spravato coverage. Check the plan’s approval guidelines and verify that all required clinical documentation is in place to support the diagnosis. Required documentation typically includes:
- Clinical diagnosis with appropriate ICD-10 codes
- History of previous treatment failures
- Dosing and frequency information
- Letter of Medical Necessity, if requested
- Supporting clinical evidence
Check with each payer for specific PA criteria. Some require demonstration of treatment resistance through failed trials of multiple antidepressant classes.
Spravato Billing Codes
Proper coding is essential for reimbursement of Spravato, and the codes you use depend on how the medication is obtained.
HCPCS Codes For Spravato
For most commercial insurers, the main HCPCS code for Spravato is S0013, which represents 1 mg of esketamine nasal spray. This code is specific to the product and helps streamline claim handling for non-Medicare plans.
Commercial insurance carriers rely on S codes for reporting medications, supplies, and certain services. CMS has also created an HCPCS identifier for Spravato that commercial payers can use.
Note: According to the official update of the HCPCS code 2026, S0013 has been deleted, and J0013 has been added as the new HCPCS code for reporting Spravato (esketamine) for applicable payers. Providers should verify payer-specific guidance and update billing workflows accordingly to avoid claim denials.
J Codes for Spravato
J3490, which is an unclassified drug code used by some insurers in place of S0013. Since it is not tied to a specific drug, you must submit extra details with the claim.
Important points about J3490:
- It is not specific to any medication
- It is always billed as a single unit
- It requires additional documentation
- Rules depend on the payer
Because policies differ among insurers, it is important to verify local billing requirements before filing claims.
CPT Codes for Spravato
CPT codes differ based on whether you use Medicare’s bundled G codes or separate drug and service reporting.
G Codes for Medicare (Bundled):
Two specific codes apply to Spravato billing:
- G2082: Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care provider and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
- G2083: Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care provider and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
Selection depends on the dose administered. The 2-hour post-administration period is consistent with REMS requirements and remains the same for both doses.
Important G code restrictions:
- Bundled G codes can only be billed when the product is acquired by an office through a specialty distributor
- Non-Medicare payers may choose to accept the G codes, but are not required to do so!
E/M Codes for Spravato Service Billing
When using specialty pharmacy procurement or non-Medicare payers accepting unbundled coding, report E/M codes separately. Evaluation and Management (E/M) codes are types of CPT® codes used for billing purposes and to describe visits and services that involve evaluating and managing patient health, including time spent with the patient.
For established patients (most common):
- 99212: 10 minutes minimum (straightforward medical decision making)
- 99213: 20 minutes minimum (low level medical decision making)
- 99214: 30 minutes minimum (moderate level medical decision making)
- 99215: 40 minutes minimum (high level medical decision making)
For new patients:
- 99202: 15 minutes minimum (straightforward medical decision making)
- 99203: 30 minutes minimum (low level medical decision making)
- 99204: 45 minutes minimum (moderate level medical decision making)
- 99205: 60 minutes minimum (high level medical decision-making)
Time alone may be used to select the appropriate E/M codes. For coding purposes, the time for these services is the total time on the date of the encounter.
Prolonged Service Codes For Spravato
Because Spravato requires 2-hour monitoring, prolonged service codes often apply.
For a physician or a qualified healthcare professional, time:
- 99417: Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time.
- G2212: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes.
Code 99417 is used only when the office or other outpatient service has been selected using time alone as the basis and only after the minimum time required to report the highest-level service (99205 or 99215) has been exceeded by 15 minutes.
For clinical staff time under physician supervision:
99415: Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour.
99416: Each additional 30 minutes (List separately in addition to code for prolonged service).
Critical restrictions:
- Do not report 99417 or G2212 on the same date of service as the Prolonged Clinical Staff Service codes (99415, 99416)
- Neither 99417 or G2212 may be reported with Spravato G codes (G2082 and G2083)
- 99415 and 99416 may not be reported for more than 2 simultaneous patients
ICD Codes for Spravato
There is no ICD-10-CM code for treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation or behavior. You must use codes that reflect the patient’s current depressive state.
For patients new to Spravato:
- 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
- R45.851: Suicidal Ideations
For patients already receiving Spravato, showing improvement:
- F32.4: Major depressive disorder, single episode, in partial remission
- F32.5: Major depressive disorder, single episode, in full remission
- F33.41: Major depressive disorder, recurrent, in partial remission
- F33.42: Major depressive disorder, recurrent, in full remission
Use diagnosis codes to the highest level of specificity for the date of service and enter the diagnoses in priority order.
POS Codes for Spravato
Place of Service (POS) codes identify the location where professional services are provided and are required on all CMS-1500 claims. They indicate the provider’s face-to-face encounter setting:
- POS 11 – Office: Ambulatory provider office, not part of hospital or facility.
- POS 19 – Off Campus Outpatient Hospital: Hospital-based department off the main campus for non-inpatient diagnostic, therapeutic, or rehab services.
- POS 22 – On Campus Outpatient Hospital: Hospital main campus area for non-inpatient diagnostic, therapeutic, or rehab services.
- POS 53 – Community Mental Health Center: Provides outpatient, emergency, partial hospitalization, or psychosocial rehab services, including specialized programs for children, the elderly, and chronically ill individuals.
Unit Counts for Spravato
Accurate unit reporting prevents denials and underpayment.
For S0013 drug code: Enter number of HCPCS units based on dose administered (1 mg = 1 unit).
- 56 mg dose = 56 units
- 84 mg dose = 84 units
For G codes: Enter 1 unit for the G code as it describes both drug and related services. Report G2082 or G2083 as 1 unit regardless of whether it covers 56 mg or 84 mg.
For E/M codes: Report appropriate E/M code; enter 1 unit.
For prolonged service codes, units vary by time:
For 99417 with established patients:
- 55-69 minutes total: 99215 x1 and 99417 x1
- 70-84 minutes total: 99215 x1 and 99417 x2
- 85+ minutes: 99215 x1 and 99417 x3 or more for each additional 15 minutes
For G2212 with established patients:
- 69-83 minutes total: 99215 x1 and G2212 x1
- 84-98 minutes total: 99215 x1 and G2212 x2
- 99+ minutes: 99215 x1 and G2212 x3 or more for each additional 15 minutes
Documentation Requirements For Spravato
Thorough documentation supports medical necessity and ensures reimbursement. Time spent with the patient must be clearly documented in the medical record.
Essential documentation elements include:
Clinical Justification:
- Diagnosis with supporting evidence
- Treatment history showing resistance to other therapies
- Current symptom severity
- Baseline depression scores (PHQ-9, MADRS)
Treatment Session Documentation:
- Date and time of administration
- Dose administered
- Start and end times for monitoring
- Vital signs, including blood pressure readings
- Patient response and any adverse events
- Total physician and clinical staff time
- Activities performed during the monitoring period
Activities that may be included in E/M time:
- Preparing to see the patient (review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring to and communicating with other healthcare professionals
- Documenting clinical information in the electronic or other health record
- Independently interpreting results and communicating results to the patient/family/caregiver
- Care coordination
REMS Compliance Documentation:
Spravato is intended for patient administration under the direct observation of a healthcare provider, and patients are required to be monitored by a healthcare provider for at least 2 hours.
- Healthcare setting certification status
- Patient enrollment in REMS (for outpatient settings)
- Direct observation of administration
- Two-hour post-dose monitoring completion
- Patient stability assessment before discharge
Common Billing Challenges Esketamine Clinics Face
Spravato reimbursement can be difficult to manage, and several recurring issues often lead to claim denials or slow payments.
- Understanding Which Benefit Applies: Coverage varies by region and by the patient’s insurance design. Some plans handle Spravato under the medical benefit, others under the pharmacy benefit, and some use both. Because of this, clinics may be unsure which codes to submit or which department should receive the claim.
- Procurement Mismatches: Bundled G codes are only appropriate when the practice purchases Spravato directly from a specialty distributor. These codes cannot be used if the drug is supplied through a specialty pharmacy, and doing so will result in an automatic denial.
- Incomplete Time Documentation: Extended service codes require clear, detailed time tracking. Codes like 99417 or G2212 cannot be billed unless the full 15-minute threshold is met. If the time records are incomplete, the codes cannot be supported.
- Prior Authorization Issues: A large share of medication denials can be avoided. Many delays stem from missing clinical details, insufficient treatment history, or failure to demonstrate why the therapy is necessary.
- REMS-Related Errors: Spravato cannot be sent home with a patient under any circumstances. Any break in REMS protocol can expose a clinic to risk and may interfere with payment.
- Differences in Payer Rules: Insurance plans vary widely in how they want Spravato services coded. Requirements for codes, modifiers, and documentation differ, so checking each payer’s expectations is essential.
- Unit Reporting Errors: A frequent mistake involves the number of units billed for Spravato services. Clinics must report the total milligrams administered, yet some mistakenly use the number of devices instead of converting to milligram units.
Final Words
Spravato billing requires specialized knowledge of complex coding requirements, strict compliance with REMS regulations, and careful attention to payer-specific policies. Success requires understanding patients’ benefits, choosing appropriate codes based on procurement method, documenting time and medical necessity thoroughly, and staying current with changing payer policies.
This is where FC Billing delivers real value. Our Spravato billing solution is designed specifically for esketamine clinics, with REMS-compliant workflows, accurate CPT and HCPCS coding, and payer-specific billing strategies. We handle benefit verification, prior authorizations, and time-based documentation while actively monitoring claims to reduce denials and fix Spravato underpayments, allowing providers to stay compliant and focus on patient care.
