Transcranial Magnetic Stimulation Billing: CPT 90867–90869 with Modifier Updates

With the passing years, TMS has evolved from an experimental method to a commonly used clinical treatment, especially for medication-resistant major depressive disorder. The FDA approved its use in 2008 for treating depression and has since become more recognized for its use in other applications for mental health.

With increased clinical popularity of TMS, it has also gained broader public and private payer coverage. This rise in demand makes accurate and up-to-date billing practices more essential than ever. Thereby, mental health providers must be well-versed in selecting the correct CPT codes, applying modifiers appropriately, and staying compliant with evolving payer-specific policies.

This blog outlines the key coding, modifier, and billing updates for TMS services to help practices stay compliant and optimize reimbursement as payer rules.

TMS Billing Updates

Recent updates to insurance and state Medicaid policies have improved access to TMS but still require strict billing and documentation practices for approval and reimbursement. These updates are:

• Coverage and Authorization Requirements

Medi-Cal now accepts CPT codes 90867, 90868, and 90869 as a routine covered benefit for patients 15 years and above, effective August 1, 2024. Nevertheless, a Treatment Authorization Request is still necessary. On the other hand, commercial payers may need prior authorization, although their procedures and documentation may vary. Providers must include diagnosis details, prior treatment attempts, proposed session schedule, and expected outcomes in their authorization requests.

• Verifying Payer-Specific Policies

There can be varied rules of coverage for treatment with TMS by each payor. It can be related to the frequency of sessions allowed, required ICD-10 diagnosis codes (e.g., F32.2 for major depressive disorder), and age restrictions. In fact, checking the patient's insurance plan and individual billing requirements of each payor in advance avoids denials and achieves smoother claim processing.

• Documentation for Clean Claims

Successful billing relies significantly on adequate documentation. Proper patient identifiers, coil placement, date and time, motor threshold information, and patient response to treatment must accompany each session. Otherwise, you have to deal with the rejections, delays, or audit of claims due to unclear or incomplete documentation. Therefore, utilizing electronic medical record (EMR) templates facilitates ease of use and adherence.

Coding Updates

TMS billing uses specific CPT codes to describe different parts of the treatment process. Each code represents a unique type of service and must be selected based on what is actually performed during the session. These updates include:

• CPT Code 90867 – Initial Session

This code is used for the first TMS session in a treatment cycle. It includes preparation steps such as determining the motor threshold and setting up the treatment protocol. It must be billed only once for each course of treatment and not be repeated in a period of six weeks. To support the use of this code, proper and accurate documentation of the initial assessment, threshold settings, and patient consent is essential.

• CPT Code 90868 – Subsequent Sessions

This code is used for each follow-up TMS session after the initial setup. It is billed more often than any other code in a treatment plan, as patients will typically have several sessions over the course of a few weeks. Every session should be documented with information like position of the coil, duration of the treatment,  and response from the patient. However, it is important to remember that providers must not bill this code on the same date as code 90869.

• CPT Code 90869 – Re-Mapping Only

This code is used when a provider recalculates the motor threshold without delivering an actual treatment. It is typically required when there are changes in the treatment protocol or if the patient’s condition has shifted significantly. It cannot be billed on the same day as 90867 or 90868. Documentation should clearly explain the medical reason for remapping and show that no treatment session was performed.

Modifier Updates

Modifiers are used in TMS billing to show that services provided on the same day are separate and medically necessary. They help ensure that providers are properly reimbursed for distinct services without billing conflicts. These include:

• Modifier 25

Separate E/M Service on Same Day

This modifier is utilized when a physician provides a significant and separately identifiable E/M service on the same day as a TMS session. For instance, if the physician evaluates medication side effects, adjusts the treatment plan, or addresses unrelated mental health concerns during the same visit, Modifier 25 should be appended to the E/M code (e.g., 99213). This modifier indicates that the E/M service is distinct from the TMS procedure and ensures separate reimbursement. However, documentation must clearly include separate progress notes and medical necessity for the E/M service.

• Modifier 59

Distinct Psychotherapy or Procedure

This modifier is utilized when a separate, non-E/M service, i.e., psychotherapy, is provided on the same day as TMS treatment. It is applicable when the services are provided at different times, in different locations, or for different indications. For instance, a patient can be given TMS in the morning and come back later for a session of psychotherapy. The modifier signals that these are not overlapping or bundled services to be separated by the time stamps and separate session notes.

• Importance of Modifier Use

Modifiers should be used properly to ensure complete reimbursement and avoid denials for bundling. Both Modifier 25 and Modifier 59 should be supported by clear and detailed documentation. However, providers must not use these modifiers on a routine basis, instead apply them only when the services are genuinely distinct and separately required.

Conclusion

Billing for TMS is uniquely complex. Unlike standard mental health services, TMS involves procedural coding, technical documentation, strict medical necessity criteria, and payer-specific coverage rules that often change without warning. In fact, poorly handled billing can result in lost revenue, compliance risks, and barriers to patient care continuity. As TMS becomes a standard treatment for medication-resistant depression, the pressure on practices to manage billing with precision continues to grow. With changing policies, providers need to keep up and adapt their billing practices to the expectations of payers.

In order to deal with these challenges, you can outsource TMS billing to professional partners like 24/7 Medical Billing Services. With a deep knowledge of TMS-exclusive coding, modifiers, and payer policy, our experts can assist mental health professionals in concentrating on providing quality treatment.

FAQs

Q1. Do TMS sessions require a separate NPI for billing?

Billing can be done under the clinic or provider’s existing NPI if properly credentialed.

Q2. Is TMS therapy covered under Medicare Advantage plans?

Many Medicare Advantage plans offer TMS coverage, but eligibility criteria and prior auth may vary by provider.

Q3. How often should motor threshold re-mapping be billed?

Only when medically necessary; routine or same-day billing with treatment codes is not allowed.

Q4. Can TMS be billed under telehealth services?

TMS must be performed in person and is not reimbursable under telehealth billing guidelines.

Q5.  Is group TMS therapy billable under these codes?

CPT 90867–90869 are intended for individual sessions only, not group therapy settings.

Q6. Can TMS be billed as part of a bundled mental health package?

TMS is billed separately due to its procedural nature and unique codes.