TMS Therapy Billing and Coding Guide: CPT 90867, 90868, 90869 and Prior Authorization

TMS therapy billing codes are CPT 90867, 90868 and 90869. CPT 90867 covers the first treatment, including cortical mapping and motor threshold determination, and you bill it once per course. Each later treatment session uses 90868, while 90869 replaces 90868 on any day the motor threshold is re-determined. Getting paid, however, depends less on the codes than on proving treatment-resistant depression and securing approval before the first session.

This guide is for psychiatrists, TMS clinic owners and billing staff. It explains CPT 90867 billing guidelines, how the three codes fit together across a course, TMS prior authorization requirements, Medicare LCD rules, and the documentation that protects transcranial magnetic stimulation reimbursement.

TMS Therapy Billing Codes Explained

CPT has three TMS therapy billing codes, and every TMS claim uses at least one of them. Each one describes a different part of a course of treatment, so the right code depends on what happened at that visit.

In short, a course starts with one 90867, continues with 90868 for routine sessions, and uses 90869 whenever the clinician repeats the motor threshold, for example after a medication change. Never bill 90868 and 90869 for the same session.

CPT 90867 Billing Guidelines

CPT 90867 billing guidelines matter because this code carries the most work and draws the most scrutiny. Report it once at the start of a course. It includes cortical mapping, finding the motor threshold, and delivering and managing the first treatment, so do not add 90868 or 90869 for that same session.

If a patient finishes a course and later starts a new course after a relapse, many payers allow a new 90867, but only with a new authorization and documentation that supports retreatment. Likewise, you can bill a separate psychiatric evaluation or medication management visit on the same day as an E/M, with modifier 25 when it is significant and separately identifiable from the TMS work. Our psychiatry billing guidelines cover E/M and psychotherapy coding in more depth.

Who Qualifies: Treatment-Resistant Depression

Almost every payer ties TMS coverage to treatment-resistant depression (TRD). Medicare’s TMS local coverage determination for the Northeast and upper Midwest is a useful example. It covers repetitive TMS for adults with a confirmed diagnosis of major depressive disorder, single or recurrent episode, when at least one of these is true:

• The patient did not respond to antidepressant trials from at least two different agent classes, each at an adequate dose and duration, in the current episode.
• Side effects from at least two medication classes kept the patient from tolerating them.
• TMS worked for the patient in a previous episode.
• The patient is receiving electroconvulsive therapy, and TMS is a less invasive option.

The same LCD also expects a trial of evidence-based psychotherapy without significant improvement, measured with a standardized depression rating scale. Commercial plans use similar criteria, though the number of failed medications and the required scales vary. Therefore, read each payer’s medical policy before you request approval.

Common Exclusions

Coverage policies usually exclude or limit TMS for patients with a seizure disorder, active psychosis in the current episode, certain neurological conditions, or implanted metal or magnetic-sensitive devices near the coil. Maintenance TMS, meaning ongoing sessions after a successful course, is generally not covered.

TMS Prior Authorization Requirements

TMS prior authorization requirements are where most claims are won or lost. Commercial plans and Medicaid programs almost always require approval before the first session, and many approve a set number of sessions. A typical request includes:

• The diagnosis, with the ICD-10-CM code for the current depressive episode.
• Each antidepressant trial: drug, class, dose, duration and why it failed.
• The psychotherapy trial: type, frequency, duration and response.
• Baseline depression rating scale scores, such as PHQ-9 or HAM-D, if the payer names one.
• A screening for exclusions, including seizure history and implanted devices.
• The treatment plan: device, protocol, number of sessions and any taper.

Medicare generally does not require prior authorization for TMS. Even so, the same documentation must be in the chart, because the MAC can deny or recoup claims that fail the LCD criteria. Our team at health insurance eligibility verification checks benefits and authorization rules before treatment starts.

ICD-10 Codes and Medical Necessity

Payers decide medical necessity first by the diagnosis code. Many accept only severe major depressive disorder without psychotic features. For example, one Medicare billing and coding article lists F32.2 (single episode, severe, without psychotic features) and F33.2 (recurrent, severe, without psychotic features) as covered codes for TMS. As a result, a claim with an unspecified or mild depression code is likely to deny. The Medicare TMS billing and coding article shows how one MAC lists the covered codes; check your own MAC and each commercial plan.

Transcranial Magnetic Stimulation Reimbursement

Transcranial magnetic stimulation reimbursement depends on the payer, the place of service and your contract. Medicare pays TMS under the physician fee schedule, so rates vary by locality. Commercial rates depend on your contract, and some plans pay a bundled rate for a whole course.

To protect revenue across a course, track three things for every patient:

Authorized sessions. Compare sessions billed with sessions approved, and request an extension before you run out.

Authorization dates. Sessions outside the approved window usually deny, even when the count is fine.

Code sequence. One 90867 per course, then 90868, with 90869 only on re-determination days.

Who Can Bill and Supervise TMS

TMS is usually delivered by a trained technician, but the claim goes out under the physician. Medicare LCDs require an order from a physician who has examined the patient and has TMS experience, and they require direct physician supervision during treatment. In other words, the physician must be in the office suite, though not necessarily in the room. Some MACs let qualified nurse practitioners or physician assistants order TMS within their state scope of practice, but supervision rules still apply. Commercial plans set their own rules, so check who may order, supervise and bill before you start.

Most practices bill TMS with place of service 11 for an office. If you treat patients in a hospital outpatient department or a facility setting, payment and billing rules change, so confirm the correct place of service and claim form with each payer.

TMS Therapy Billing Codes for Retreatment and Second Courses

Relapse is common, and many patients return for another course. Medicare LCDs allow retreatment when the patient met the original criteria, responded to the first course with more than 50% improvement on a standard depression rating scale, and later relapsed. Commercial plans often add a waiting period between courses or ask for new medication trials. For this reason, keep the before-and-after rating scale scores from every course, because they are the main proof that TMS worked and that retreatment is reasonable.

How to Appeal a Denied TMS Claim

When a payer denies a TMS claim or authorization, first read the reason code and the payer’s medical policy. Most denials come from missing medication details, an unsupported diagnosis code, or sessions outside the approved window. Then gather the records that answer the specific reason, write a short letter that walks through each coverage criterion, and attach the rating scale scores. Finally, track the appeal deadline, since late appeals are rarely accepted.

Example: Using TMS Therapy Billing Codes Across a Course

Consider a hypothetical adult patient with recurrent severe major depressive disorder (F33.2). She failed two antidepressants from different classes and twelve weeks of cognitive behavioral therapy. First, the clinic submits a prior authorization with her medication history, therapy notes and baseline PHQ-9, and the plan approves the full course. Next, on day one, the clinic bills 90867. For the following daily sessions, it bills 90868. Then, in week three, her psychiatrist changes a medication and repeats the motor threshold, so the clinic bills that session as 90869 instead of 90868. Finally, the clinic stops billing when the authorized sessions are used and documents her follow-up rating scale scores.

Documentation That Supports TMS Therapy Billing Codes

• Confirmed MDD diagnosis and severity, coded to the highest specificity.
• Medication trials with class, dose, duration and outcome.
• Psychotherapy trial details and response.
• Standardized rating scale scores at baseline and during treatment.
• Exclusion screening, including seizure history and implanted devices.
• Order from a qualified physician and evidence of physician supervision.
• Device name and FDA clearance, motor threshold and treatment parameters for each session.
• Authorization number, approved session count and dates.

Common Mistakes With TMS Therapy Billing Codes

• Billing 90867 more than once in a course.
• Billing 90868 and 90869 for the same session.
• Starting treatment before the authorization is approved.
• Using an unspecified or mild depression code.
• Billing sessions beyond the approved count or date range.
• Billing maintenance sessions after the course ends.

Each of these errors is easy to prevent with a pre-billing check that compares TMS therapy billing codes with the authorization. If TMS claims or authorizations are slowing your practice down, our behavioral health billing services handle authorizations, coding and follow-up for TMS clinics. Our guide to behavioral health billing denials covers the denial codes TMS practices see most.

Frequently Asked Questions