Services › RCM › TMS & Spravato Billing
TMS and Spravato are two of the most reimbursement-complex treatments in modern psychiatry. Unique CPT codes, REMS requirements, strict prior authorization rules, and payer-specific session limits make every claim a minefield. ParaMed's specialized mental health billing team turns complexity into clean, consistent revenue.
Non-invasive, FDA-cleared treatment using magnetic pulses to stimulate neural activity — covered by Medicare and most major commercial payers for treatment-resistant depression, OCD, and anxious depression. Each treatment cycle involves 30–36 sessions with precise CPT billing requirements.
FDA-approved intranasal esketamine for treatment-resistant depression and MDD with suicidal ideation — administered in-office under REMS-mandated supervision for 2 hours post-dose. Billing spans drug administration, evaluation, and monitoring — each with precise coding requirements.
Transcranial Magnetic Stimulation uses a coil placed against the scalp to deliver focused magnetic pulses to specific brain regions. A standard TMS course involves 30–36 daily sessions over 6–9 weeks, with each session lasting 18–37 minutes.
Payers cover TMS for MDD, OCD, and anxious depression — but documentation, diagnosis codes, and session limits vary significantly by carrier.
FDA cleared for MDD (2008), OCD (2018), and anxious depression (2021)
Requires separate mapping session billed before treatment initiation
Covered by Medicare, Medicaid, and most commercial payers with prior authorization
Spravato is an FDA-approved intranasal formulation of esketamine indicated for treatment-resistant depression and MDD with suicidal ideation. It must be administered in a certified healthcare setting under direct observation with 2-hour post-dose monitoring.
This in-office supervision requirement creates significant billing complexity that most practices fail to capture fully.
Requires REMS certification for both prescriber and dispensing site before any dose
Drug cost averages $590–$885 per session — coding errors cost thousands per month
Two-hour monitoring can be billed separately with prolonged service codes if documented correctly
Industry Alert: TMS and Spravato claims have denial rates 3–5× higher than standard psychiatric services at practices without dedicated mental health billing specialists. Each denied session represents $150–$885 in lost revenue. ParaMed's specialized billing infrastructure is built specifically for these complex treatment types.
The motor threshold mapping session (CPT 90867) must be billed before treatment sessions begin. Billing treatment codes without the preceding mapping code triggers automatic rejection at most payers.
Both the prescribing clinician and the clinical setting must maintain active REMS enrollment. An expired or missing certification causes automatic denial of the entire session including drug cost.
TMS requires prior authorization at virtually every commercial payer. Billing outside the authorization parameters — even by a single session — results in denial with limited appeal options.
The Spravato drug itself (HCPCS S0013) must be billed separately from the administration and monitoring visit. Many practices fail to bill the drug code entirely — losing $590–$885 per session.
Both treatments require documented evidence of treatment-resistant depression. If the record doesn't clearly document prior treatment history and diagnostic criteria, payers deny on clinical review.
Most payers authorize a specific number of TMS sessions — typically 30–36. Continuing to bill after the approved count without extension authorization results in automatic denial.
TMS billing requires precise application of a tiered CPT code set that differentiates between the initial mapping session, standard treatment sessions, and subsequent re-mapping. Each code carries different documentation requirements, time components, and payer-specific coverage rules.
ParaMed builds a complete billing schedule for every patient before treatment begins — mapping every planned session to the correct code, identifying authorization parameters, and flagging any coverage limitations.
| CPT Code | Description | When Used |
|---|---|---|
| 90867 | TMS Treatment — Initial Motor Threshold Determination | First session only — required mapping |
| 90868 | TMS Treatment — Subsequent Delivery | All standard treatment sessions after mapping |
| 90869 | TMS Treatment — Subsequent Motor Threshold Re-Determination | Re-mapping clinically required mid-course |
| 90875 | Deep TMS Treatment — Initial Session | dTMS (Brainsway) — initial mapping only |
| 90876 | Deep TMS Treatment — Subsequent Sessions | dTMS ongoing treatment sessions |
| 99213–99214 | E&M Office Visit | Billed separately when significant E&M occurs |
AAPC-certified coders specialize exclusively in TMS billing protocols and payer-specific coverage policies.
REMS certification status verified before every session — proactive 60-day renewal tracking.
Spravato billing involves multiple distinct billable components per visit — the drug itself, the evaluation and management service, and the 2-hour monitoring period. Each component requires different codes, documentation, and claims submission pathways.
Spravato is a Schedule III controlled substance administered under an FDA REMS program. The prescribing clinician, the dispensing site, and any pharmacy must all maintain active REMS enrollment. Claims submitted without valid REMS certification will be denied in full — including the drug cost. ParaMed verifies and tracks REMS status for every provider and location before every billing cycle.
| Code | Description | Avg Reimbursement |
|---|---|---|
| S0013 | Esketamine nasal spray — per dose (HCPCS) | $590–$885 per session |
| 99213/99214 | E&M office visit — moderate complexity (25 modifier) | $110–$190 |
| 99354 | Prolonged service — first additional 30–74 min | $50–$80 |
| 99355 | Prolonged service — each additional 30 min beyond 99354 | $40–$60 |
| 96160 | Health risk assessment — patient-focused | $25–$40 (when applicable) |
From first contact to final payment — every component of TMS and Spravato revenue cycle management is covered. No outsourced tasks, no knowledge gaps, no lost sessions.
Prior authorization is the single biggest revenue risk for both TMS and Spravato. ParaMed submits, tracks, appeals, and extends every authorization — managing the complete PA lifecycle so sessions are never billed outside approved parameters.
The Spravato REMS program creates administrative obligations that directly affect your ability to bill. ParaMed manages all REMS-related compliance so your program never faces a billing interruption due to certification gaps.
Every session coded by a specialist who knows TMS and Spravato billing specifically — not a generalist. We capture every billable code with correct modifiers.
TMS and Spravato denials are common — and complex to appeal without clinical expertise. ParaMed handles every appeal with the specific documentation that moves claims from denied to paid.
Before a patient begins treatment, your practice needs to know exactly how their insurance covers TMS or Spravato — including deductible, out-of-pocket, auth requirements, and session limits.
TMS treatment courses run for weeks. With dozens of sessions per patient and multiple patients in treatment simultaneously, you need real-time revenue visibility. ParaMed provides it.
📊 See Our Reporting DashboardEvery session billed, pending, and paid — per patient, per treatment course
Real-time PA status, session counts, and renewal alerts
All providers and locations — certification status and expiry dates
TMS vs. Spravato collections, denial rates, and A/R separated clearly
A successful TMS or Spravato PA isn't just submitting a form — it's building a complete clinical case that demonstrates medical necessity, prior treatment failure, and treatment-appropriateness in the specific language each payer recognizes.
Before a PA is filed, we verify insurance, confirm TMS/Spravato coverage, identify the exact PA submission address and clinical criteria, and determine required prior treatment documentation needed for medical necessity approval.
We review the patient's chart and assemble a complete clinical documentation package — psychiatric diagnosis, PHQ-9 scores, documented medication trials with dosages and durations, and clinician rationale.
The complete PA package is submitted via the payer's preferred channel within 48 hours of receiving the referral. All required forms, clinical documentation, and physician attestation are included.
We track every PA through adjudication with status checks every 3–5 business days. Pending requests exceeding standard turnaround times are escalated immediately.
Denied PAs are reviewed for root cause, corrected with additional clinical evidence, and formally appealed. When medical necessity denials persist, we coordinate peer-to-peer review between your physician and the payer's medical director.
The REMS for Spravato is a federally mandated program requiring specific certifications, documentation, and protocols before any esketamine dose can be dispensed or administered. Non-compliance can result in FDA action, prescribing privilege suspension, and significant regulatory liability.
ParaMed's REMS management covers every compliance obligation:
Most billing companies have never successfully billed a TMS claim or a Spravato session. ParaMed's specialized mental health billing team has — thousands of times.
Dedicated coders who work exclusively with TMS, Spravato, and other complex psychiatric services — not a generalist team.
We onboard your practice and begin processing claims within 48–72 hours while simultaneously working your existing denial backlog.
We know which payers cover TMS for OCD, which require specific PHQ-9 thresholds, and which have session limits that differ from their published policies.
ParaMed earns a percentage of collections — we only get paid when you get paid. Our entire incentive is to collect every dollar, every session.
Coverage rules, prior authorization requirements, and session limits vary dramatically across payer types. ParaMed knows every payer's specific requirements and bills accordingly every time.
Covers TMS for MDD under LCD L37086/L37087. Requires documentation of 4+ antidepressant failures. Spravato covered under Part B as a physician-administered drug.
Coverage for TMS and Spravato varies significantly by state. Some programs cover TMS with PA; others have it non-covered. Spravato is covered in most states with varying PA requirements.
BCBS plans generally cover TMS for MDD with PA and documented treatment failure. Coverage criteria vary by local plan. Spravato coverage varies — some cover under medical, some under pharmacy benefit.
Covers TMS for MDD and OCD with PA under their behavioral health medical policy. Has some of the more detailed PA requirements including specific PHQ-9 scores.
UHC covers TMS for MDD with PA. Coverage policy is among the more favorable for TMS, with PA criteria that can be met with adequate documentation.
Cigna covers TMS with PA under their Coverage Policy Bulletin. Other commercial payers have increasingly expanded TMS coverage as evidence has grown.
A specialized mental health billing advisor will contact you within 1 business day.
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