CPT Code 90867 represents the initial administration of Transcranial Magnetic Stimulation (TMS), a specialized psychiatric treatment gaining recognition for its effectiveness in treating major depressive disorder and other treatment-resistant conditions. This code is essential for proper billing and reimbursement of the first session in a series of TMS treatments.

This guide provides healthcare professionals with critical information about implementing, billing, and meeting regulatory requirements for CPT code 90867. Whether you're a psychiatrist, billing specialist, or practice administrator, you'll find valuable insights to effectively navigate TMS therapy billing.

What Is CPT Code 90867?

CPT Code 90867 specifically describes the "Therapeutic repetitive transcranial magnetic stimulation treatment; initial, including cortical mapping, motor threshold determination, delivery and management." It represents the first session in a series of TMS treatments, which encompasses several critical components that distinguish it from subsequent treatment sessions.

This initial TMS session is more comprehensive than follow-up treatments, as it includes several essential procedures:

Cortical Mapping

The process of identifying the precise location on the skull where the magnetic coil should be positioned to target the appropriate brain region.

Motor Threshold Determination

Establishing the minimum intensity needed to elicit a motor response, which serves as a baseline for calibrating treatment intensity.

Initial Delivery

The first administration of the magnetic pulses according to the prescribed protocol.

Treatment Planning and Management

Documentation of the treatment parameters and the patient's response.

Unlike subsequent sessions (billed under CPT code 90868), this initial session typically requires more time and clinical expertise to properly establish treatment parameters that will guide the entire course of therapy.

Who Can Bill CPT Code 90867?

The ability to bill for TMS therapy using CPT code 90867 is restricted to specific healthcare providers who meet the necessary qualifications and practice in appropriate clinical settings. Check with your insurance provider to confirm coverage and eligibility, as CPT code 90867 for TMS therapy can only be billed by specific qualified healthcare providers practicing in approved clinical settings.

Qualified Healthcare Providers

Appropriate Clinical Settings

Many insurance companies and Medicare have specific requirements regarding provider qualifications, facility accreditation, and documentation standards that must be met to obtain reimbursement for TMS therapy.

Provider Requirements

Most payers require providers to meet specific criteria, including:

• Completion of manufacturer-provided training on the specific TMS device

• Documentation of the supervising physician's credentials and presence

• Adherence to FDA-approved protocols and indications

• Proper certification of the treatment facility

TMS Initial Session vs. Subsequent Sessions: CPT Code 90867 vs. 90868

Understanding the distinction between the initial TMS session (90867) and subsequent sessions (90868) is critical for accurate billing and appropriate reimbursement.

A typical course of TMS therapy involves one initial session (90867) followed by multiple subsequent sessions (90868) over a period of 4-6 weeks. In some cases, a re-mapping session may be necessary during treatment, which would again be billed using the 90867 code.

There is also a related code, 90869, which represents TMS therapy that includes subsequent motor threshold re-determination. This code may be used when a patient's treatment parameters need significant adjustment during therapy.

Cost of TMS Therapy Initial Session (CPT Code 90867)

The cost of the initial TMS therapy session billed under CPT code 90867 varies significantly based on several factors. Understanding these cost variables is important for providers establishing fee schedules and for patients navigating their financial responsibility.

It's important to note that these figures below are general estimates, and actual costs may differ. Insurance coverage for TMS therapy varies, and many providers require prior authorization before commencing treatment.

Therefore, it's crucial to consult with your insurance provider to understand your specific coverage details and any out-of-pocket expenses you may incur.

Typical Price Ranges

Insurance Coverage for CPT Code 90867

Insurance coverage for TMS therapy has expanded significantly in recent years as evidence supporting its efficacy has grown. However, coverage policies vary considerably across payers and often include specific requirements that must be met before authorization is granted.

Medicare Coverage

Medicare covers TMS therapy for treatment-resistant depression under specific circumstances. Requirements typically include:

Commercial Insurance Coverage

Most major commercial insurers now provide coverage for TMS therapy, though with varying criteria:

Common Coverage Requirements

• Documented treatment-resistant depression (typically failure of 2-4 medication trials)

• Previous psychotherapy trials

• Screening for contraindications

• Prior authorization requirements

• Limitation to FDA-approved indications

Medicaid Coverage

Coverage varies significantly by state, with some providing comprehensive coverage similar to Medicare while others may have more restrictive criteria or may not cover TMS therapy at all.

Coverage Challenges

Several areas present consistent challenges for TMS coverage:

Off-label Uses

Conditions other than Major Depressive Disorder often face coverage barriers.

Provider Credentials

Some payers require specific provider credentials beyond state licensing.

Maintenance Treatment

Sessions beyond the initial acute treatment phase may have different coverage policies.

Documentation Requirements

Can be extensive and time-consuming to prepare properly.

Providers should establish a robust prior authorization and verification process specifically for TMS therapy to minimize denials and payment delays.

Common Billing Issues with CPT Code 90867

Despite the growing acceptance of TMS therapy, several common billing and reimbursement challenges persist. Identifying and addressing these issues proactively can help practices maintain healthy revenue cycles.

Prior Authorization Delays

TMS typically requires prior authorization, which can be time-consuming. Develop streamlined workflows with dedicated staff for TMS authorizations and prepare comprehensive documentation packages in advance.

Incorrect Code Sequencing

Using 90867 for sessions other than the initial treatment or mapping is a common error. Implement clear coding guidelines and conduct regular audits of TMS billing.

Diagnostic Code Mismatches

Using ICD-10 codes that don't align with approved indications can cause denials. Create a list of approved diagnosis codes for TMS therapy based on payer policies.

Documentation Deficiencies

Inadequate documentation of treatment parameters or patient responses is a frequent issue. Develop standardized documentation templates specific to initial TMS sessions.

Units of Service Errors

Billing multiple units of 90867 inappropriately can trigger audits. Implement system alerts to prevent multiple submissions of initial session codes.

Medical Necessity Challenges

Insufficient evidence of treatment resistance or prior therapy failures may lead to coverage denials. Create comprehensive intake protocols that document treatment history thoroughly.

Place of Service Issues

Incorrect facility vs. non-facility designations can affect reimbursement. Confirm appropriate place of service codes for your specific treatment setting.

Bundling and Unbundling Concerns

Separately billing for services included in the 90867 code is problematic. Educate billing staff on what's included in the TMS initial session code.

Implementing a TMS-specific billing audit process can help identify and address these issues before they result in denials or payment delays.

Mistakes to Avoid When Billing CPT Code 90867

Proper billing of TMS therapy requires attention to detail and awareness of common pitfalls. Below are specific mistakes to avoid when using CPT code 90867.

• Documentation Errors: Insufficient documentation is a leading cause of claim denials for TMS therapy.

• Motor Threshold Documentation: The method used and the specific threshold value must be clearly recorded.

• Cortical Mapping Details: Documentation should include the precise location identified for treatment.

• Physician Involvement: Clear evidence of physician direction and involvement is required.

• Treatment Parameters: Intensity, frequency, and total pulses delivered should be documented.

• Medical Necessity Evidence: Include a comprehensive history of failed medication trials.

Coding Mistakes

Improper code selection or combination can lead to denied claims or payment recoupments:

Frequently Asked Questions

Can CPT code 90867 be billed more than once per treatment course?

Generally, CPT code 90867 should only be billed once at the beginning of a treatment course, as it represents the initial session, including mapping and threshold determination. However, if a significant clinical change occurs requiring complete re-mapping and new threshold determination, a second instance may be justified with appropriate documentation. Some payers may require a modifier in these circumstances.

Does CPT code 90867 include the technical component of TMS delivery?

Yes, CPT code 90867 is a comprehensive code that includes both the professional component (physician work) and the technical component (equipment, facility, and technician costs). It should not be billed with separate technical component codes or modifiers unless specifically required by certain payers.

What diagnosis codes support medical necessity for CPT code 90867?

The most commonly accepted diagnosis code is F33.2 (Major depressive disorder, recurrent, severe without psychotic features), though other depression codes may be accepted depending on the payer. Some payers may accept F32.2 (Major depressive disorder, single episode, severe without psychotic features). It's essential to check each insurer's policy for covered diagnoses. Currently, most payers only cover TMS for depression, not for other conditions like OCD or anxiety disorders.

How long must a patient fail medication trials before TMS therapy is considered medically necessary?

Most insurance policies require documentation of failure to achieve satisfactory improvement after 4-6 weeks of treatment at adequate doses for at least 2-4 antidepressant medications from at least 2 different classes. The exact requirements vary by payer, with some requiring failure of as many as 4 medication trials plus psychotherapy.

Can non-physician providers bill for CPT code 90867?

In most cases, the initial TMS session must either be performed by or directly supervised by a physician (typically a psychiatrist or neurologist).

While subsequent sessions may have more flexible supervision requirements, the initial mapping and threshold determination generally require physician involvement. Some payers may allow properly trained and certified nurse practitioners or physician assistants to bill for this service under certain circumstances.

Bottom Line

CPT code 90867 represents a critical component in the delivery and reimbursement of Transcranial Magnetic Stimulation therapy for treatment-resistant depression. As an innovative treatment modality that continues to gain clinical acceptance and insurance coverage, understanding the proper application of this code is essential for healthcare providers offering TMS services.

Successful billing for TMS therapy requires attention to detail in documentation, thorough knowledge of payer requirements, and strategic approaches to authorization and claims submission. By implementing the best practices outlined in this guide, providers can minimize claim denials, optimize reimbursement, and ultimately improve patient access to this effective treatment option.

As TMS therapy continues to evolve, with expanding indications and technological innovations, staying current with coding and billing requirements will remain an important priority for psychiatric practices and other facilities offering brain stimulation therapies.

Disclaimer

This guide is intended for informational purposes only and does not constitute legal, financial, or coding advice. CPT coding guidelines and payer policies are subject to change. Healthcare providers should consult official CPT coding resources, specific payer policies, and appropriate legal counsel to ensure compliance with current regulations and requirements. The information provided is based on coding standards and typical payer policies as of April 2025.