CPT code 90867 describes the initial session of repetitive Transcranial Magnetic Stimulation (rTMS) treatment, including cortical mapping and motor threshold determination. It is primarily reported by psychiatrists and other qualified physicians providing TMS therapy.
TMS services are commonly used in treatment-resistant depression and are subject to strict payer documentation requirements. However, appropriate and clean reimbursement depends on how well billing teams understand the CPT code.
According to the American Academy of Neurology, one in two people living in the U.S. is affected by a neurological disease or disorder. As a result, CPT code 90867 is frequently reported for reimbursements in:
- Neurology
- Psychiatry
- Related specialties
In this guide, we will discuss the following relevant to CPT code 90867:
- Official description
- Payer-specific billing and reimbursement guidelines
- Applicable modifiers
- Clinical scenarios in which the code can be reported
CPT Code 90867 – Description
According to the American Medical Association (AMA), CPT code 90867 indicates:
Therapeutic repetitive transcranial magnetic stimulation treatment; initial, including cortical mapping, motor threshold determination, delivery, and management.
Simply put, this CPT code reports the first session of a TMS treatment course, which includes all required preparatory mapping and motor threshold determination prior to delivery and ongoing treatment sessions.
Steps Involved in the First Session for 90867
As mentioned earlier, CPT code 90867 involves multiple steps, which include:
| Steps/ Components | What It Involves |
|---|---|
| Cortical Mapping | Identification of the optimal coil placement site on the skull to ensure stimulation of the targeted brain region. |
| Motor Threshold Determination | Assessment of the patient’s motor threshold to determine the appropriate stimulation intensity for treatment. |
| Initial Delivery | Delivery of the initial repetitive magnetic stimulation session according to the physician-approved treatment plan. |
| Documentation of Stimulation Parameters & Patient Response | Recording of treatment settings, stimulation parameters, and patient response to guide subsequent therapy sessions. |
Who Can Bill CPT Code 90867?
CPT code 90867 is typically reported by psychiatrists or physicians qualified to deliver TMS therapy. In some settings, services may be performed by advanced practice providers (e.g., nurse practitioners or physician assistants) when permitted under state law and payer-specific supervision and billing requirements.
Typically, the following professionals may report 90867 to bill insurers for services:
- Psychiatrists
- Neurologists
- Other physicians
- Advanced practice providers (such as PAs or NPs) may report these services when permitted under supervision requirements and state-specific laws.
Scenarios Where CPT Code 90867 is Applicable
The following are three medically appropriate scenarios in which CPT code 90867 may be reported.
Initial TMS Treatment Course
Say a 42-year-old female presents at an outpatient psychiatric clinic with persistent depressive symptoms. Although the patient has completed multiple antidepressant trials, she has not achieved adequate symptom improvement.
Therefore, the psychiatrist performs an initial TMS session that includes cortical mapping. He determines motor thresholds and delivers the initial TMS treatment. The billing team uses CPT code 90867 to report the initial treatment session.
New Episode of Care
Consider a 37-year-old female who returns to the outpatient behavioral health clinic. She experiences a recurrence of major depressive disorder. Almost a decade ago, she had completed a successful TMS treatment course.
During the visit, the psychiatrist:
- Performs cortical mapping
- Determines the motor threshold
- Delivers the initial TMS treatment session
Afterwards, the billing team reports CPT code 90867.
Initial TMS Session Following Transfer of Care
Say a 50-year-old male experiences recurrent major depressive disorder. He presents to an outpatient psychiatric clinic after previously completing a TMS treatment course from another psychiatric practice. However, the previous parameters were insufficient and did not treat the patient’s depression.
Therefore, the psychiatrist performs cortical mapping and motor threshold determination during a new initial session, and CPT code 90867 is reported for billing and reimbursement.
When Not to Use CPT Code 90867
While CPT 90867 is highly useful in neurological and psychological medical billing, it should not be used in some cases. These may include:
- CPT code 90867 is typically reported once per treatment episode and should not be repeated unless a new course of treatment is initiated or payer-specific criteria are met.
- According to the CMS guidance, under NCCI edits and payer bundling rules, CPT 90867 should not be reported on the same date of service as 90868 or 90869.
- Follow-up treatment sessions that do not include cortical mapping and motor threshold determination are typically reported with CPT code 90868.
Note: These guidelines must be followed unless supported by payer-specific requirements and exceptional circumstances.
Applicable Modifiers for CPT Code 90867
Billing teams should append applicable modifiers to CPT code 90867 as per individual payer policies. Modifiers that may be applicable in specific billing scenarios include the following:
| Modifier | Description | Usage with CPT 90867 |
|---|---|---|
| 59 | Distinct procedural service | Used when another separately identifiable service was rendered on the same day as TMS therapy and is not subject to bundling edits. |
| SA | Supervised nurse practitioner collaboration | Used when a nurse practitioner rendered a service in collaboration with a physician, typically for “incident to” billing. |
Note: XE, XS, XP, and XU are subsets of modifier 59 and should be used when appropriate to describe specific circumstances of distinct procedural services. Therefore, always review the guidelines of the specific insurance payer and the context of the session.
CPT Code 90867 – Billing & Reimbursement Guidelines
Accurate billing for CPT code 90867 may seem straightforward, but it requires vigilance. A missed requirement or incorrect modifier use can get your claim rejected. The most essential billing and reimbursement guidelines for this CPT code include:
Ensure Complete Documentation for Clean Claim Submission
Every claim must include the following documents for a clean claim:
Record Authentication
The medical record entries must include patient identifiers (full name and date of service). Each entry must be authenticated with a valid, legible signature of the rendering physician or qualified non-physician practitioner.
Face-to-Face Encounter Documentation
Clearly document face-to-face services provided by the treating physician during the initial evaluation. Additionally, if there is a significant change in the patient’s clinical or mental status, the subsequent face-to-face encounters can also be added.
Proof of Medical Necessity
Documentation must include the provider’s clinical assessment and medical decision-making, including evaluation of absolute and relative contraindications supporting medical necessity.
Record Maintenance
All documentation must be maintained in the patient’s permanent medical record and made available upon request for:
- Payer review
- Audit requests
- Compliance validation
Obtain Prior Authorization
Prior authorization is required by multiple commercial insurers and some Medicare Advantage plans before the initiation of TMS therapy. Therefore, billing teams should always obtain them before services are rendered.
Pair ICD-10-CM and CPT Code
The selected ICD-10-CM diagnosis codes and supporting medical necessity must be substantiated in the medical record. Similarly, the final CPT code reported must accurately reflect the documented procedure performed during the encounter.
Report Place of Service
CPT code 90867 can only be billed if the service is performed in person with equipment-based treatment. Other options, such as telehealth reimbursement, do not apply. Ideally, the services can be rendered in settings such as:
- Neurology practices
- Psychiatric outpatient clinics
- Dedicated TMS centers
- Hospital outpatient departments
It is necessary to add an accurate Place of Service (POS) code, depending on the treatment setting, for accurate reimbursement.
Wrapping It Up
CPT code 90867 indicates the initial session of a Transcranial Magnetic Stimulation treatment course. The procedure requires direct physician involvement and detailed supporting documentation.
Practices offering TMS therapy must get the initial session billed correctly for a successful revenue cycle. However, minimizing claim denials and ensuring appropriate reimbursement requires careful evaluation.
Not every in-house billing team is trained to accomplish this goal. Fortunately, MediBillMD’s TMS billing services help psychiatry and neurology practices resolve coding challenges with confidence.
