Depression is one of the fastest-growing health issues in the USA and the world. There are supplemental treatments for it, but many patients don’t respond to them. For these patients, transcranial magnetic stimulation (TMS) has emerged as a clinically validated, FDA-approved alternative. In fact, a consensus review shows that in real-world scenarios, up to 83% of patients with treatment-resistant depression show measurable improvement with repetitive TMS therapy.
As clinical adoption grows, so does the volume of TMS claims. Unfortunately, it also means more claim denials.
Sessions for TMS are usually billed via CPT code 90868, and we will cover everything about this code to help you bill it correctly and avoid denials. So, let’s start.
CPT Code 90868 – Description
CPT code 90868 is defined as:
“Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session.”
Let’s simplify this. 90868 is basically a psychiatric billing code. It covers every individual follow-up TMS session that takes place after the initial session, which is billed with CPT code 90867. The difference between the first session and the subsequent sessions is huge. That’s because 90867 bundles cortical mapping, motor threshold determination, and first-session delivery. On the other hand, 90868 only deals with the ongoing execution and management of TMS.
You might be wondering what exactly TMS is. Well, it is a non-invasive procedure and uses magnetic fields to stimulate the nerve cells in the brain. In most cases, it is performed to help the patient with major depressive disorder (MDD). The whole treatment usually runs for 30-36 sessions, which take about six to nine weeks. Each of these sessions is billed with 90868, except the first one.
Scenarios Where CPT Code 90868 is Applicable
To give you a clearer picture, here are a couple of real-world scenarios in which CPT code 90868 can be used:
Scenario 1
Suppose a patient comes to a psychiatric clinic. He has a documented history of MDD. He shares with the attending physician that he had already tried antidepressant medication courses twice. However, nothing seems to work. The physician performs the initial TMS session, which includes motor threshold determination and delivery. He also asks the patient to come for the follow-up sessions. This first session is billed via CPT code 90867.
The patient then comes for the next session. A trained technician positions the magnetic coil over the left dorsolateral prefrontal cortex in accordance with the established protocol. He then administers the magnetic pulses as determined by the physician. In this case, the billing department can use CPT code 90868 to bill the subsequent session.
Scenario 2
Suppose a patient is suffering from major depressive disorder. His physician has tried antidepressant treatments, but there are no visible improvements. So he obtained prior authorization, started the TMS treatment, and delivered the first session to the patient.
The treatment will have 36 sessions. So, the next day, the patient visits for his second session.
During the subsequent session, a trained technician delivers the entire TMS protocol as guided by the psychiatrist. Everything is documented properly. In the end, the billing department can use CPT code 90868 to bill this subsequent TMS session.
Applicable Modifiers for CPT Code 90868
The following modifiers can be used with CPT code 90868:
| Modifier | Short Description | Usage with CPT 90868 |
|---|---|---|
| SA | Nurse Practitioner (NP) Collaboration | NP delivers a TMS session in collaboration with a physician. |
| U7 | Medicaid Level of Care | Indicates Medicaid-specific level for TMS service. |
| 99 | Multiple Modifiers Apply | Signals additional modifiers apply to the TMS session. |
CPT Code 90868 – Billing & Reimbursement Guidelines
Here are some guidelines that are important to follow. These will help you avoid common mistakes made by billers while using CPT code 90868:
Get Prior Authorization Before Starting Treatment
Most insurance payers require prior authorization for TMS treatments. For instance, as per the updated Medi-Cal policy, CPT codes 90867, 90868, and 90869 were accepted as a routine covered benefit effective August 1, 2024, but a Treatment Authorization Request is still required. Similarly, Anthem also requires pre-authorization for 90868.
Failing to get this authorization is one of the biggest causes of claim denials.
Bill CPT 90868 Once Per Session
CPT code 90868 is billed per session, not per time unit or per pulse sequence. This means you report exactly one unit of 90868 for each subsequent treatment session.
Keep in Mind the Bundling Rules
One critical restriction applies to this code: CPT 90868 and CPT 90869 cannot be reported on the same date of service for the same patient.
Similarly, CPT 90867 should not be reported together with 90868 or 90869 under any circumstances.
Pair with Accurate ICD-10 Diagnosis Codes
Every CPT code 90868 claim must be supported by an appropriate ICD-10 diagnosis code to pass medical necessity review. For 90868, the following two diagnosis codes are used most:
- F32.2: Major depressive disorder, single episode, severe without psychotic features.
- F33.2: Major depressive disorder, recurrent severe without psychotic features.
Wrapping Up
This marks the end of our guide. However, before wrapping up, let’s summarize the important points that we discussed:
- CPT code 90868 is used to bill subsequent sessions of transcranial magnetic stimulation (TMS) treatment.
- Append appropriate modifiers to the code when necessary.
- Bill only one unit per session.
- Never use this code on the same day as 90867 and 90869.
- Fulfil the prior authorization requirement before TMS delivery and billing.
Billing can get complex, especially if you don’t have the right tools and an experienced in-house team. That’s why many practices choose to outsource this work to specialists. Many companies, like MediBillMD, offer expert TMS billing services at affordable rates.
