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A third of TMS prior authorizations end up as denial on the first pass. We work on the procedures to decide whether a course collects the authorization and its renewal or the 90867 through 90869 coding the edits demand. Our process also transcribes the motor threshold documented in every note, standard rTMS, Deep TMS, and theta-burst.
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TMS billing is the work of getting a transcranial magnetic stimulation course paid across its full 30 to 36 sessions. It opens with a prior authorization that every plan requires before the first treatment. It bills on three CPT codes, 90867 through 90869, that carry edits an office visit never does. 90867 is a per-course code, not a per-day one, and the CCI edits between the three carry a modifier indicator of zero, so a single misfire denies the claim or invites a recoupment later. MHBS TMS biller secures and renews the authorization and codes each session to its rule. The job also expects him to document the motor threshold a reviewer will check. The biller works the denials and file enrollment to increase the possibility that the payer recognizes the claim.
Inexperienced coders reverse 90868 and 90869, calling 90869 the routine code. That is wrong, and it causes denials. 90868 is the routine daily session. 90869 is the occasional re-determination. The American Academy of Family Physicians and CMS both state the TMS codes carry CCI edits with a modifier indicator of zero, which means you cannot unbundle them under any circumstances.
90867 covers the whole course once, never a second time and never the same day as 90868 or 90869. The CCI edits between them have a modifier indicator of zero and nothing unbundles a same-day pair. The claim is simply denied.
The majority of the plans want approval before session one, based on two to four failed antidepressant trials at a therapeutic dose. Start without it and the payer can refuse all 30-some sessions, after the chair time is already spent.
On a post-payment review the payer reads the note. Without the numeric motor threshold and the failed-trial history, a course that paid cleanly gets clawed back, and a single recoupment can erase months of TMS revenue.
After enough TMS accounts, the denials start to repeat. Four causes account for most of what we see, and each one is preventable before the claim goes out.
A clinic books the patient and starts treatment before the authorization is back, or files it with "failed two medications" and nothing more. Payers read that as incomplete, which is why first-pass TMS denials go around 25 to 30 percent. The record has to name each antidepressant, its class, the dose, the duration, and why the trial stopped. When it doesn't, the whole course denies after the sessions are delivered, and even the plans that recently dropped the prior-auth step for in-network providers still hold the claim to the same medical-necessity standard on the back end.
We build the authorization to the plan's actual criteria. The diagnosis, the trial-by-trial medication history, the rating-scale scores, before session one. We calendar the renewal against the approved session count and it never lapses mid-course. When a request comes back denied, we move it to a peer-to-peer review. This approach overturns a strong clinical case far more often than a written appeal.
90867 goes out twice, or lands on the same day as a delivery code, or 90869 gets used for an ordinary session where no one re-determined the threshold. Each breaks a documented CCI rule. Because those edits carry a modifier indicator of zero, no modifier rescues them and the claim is denied outright or surfaces on a later audit. The reversed-code error is common enough that published guides still get 90868 and 90869 backwards, which seeds denials for any clinic that follows them.
We bill 90867 once for the mapping session, 90868 for the daily treatments, and 90869 only when the provider genuinely re-determines the threshold. Edit checks in the EHR stop the same-day pair and the second 90867 before the claim leaves. We keep the unit count matched to the sessions on record so a mismatch never triggers review.
Sessions bill out without the motor-threshold percentage, the pulse count, or the coil location, and the claims pay. Then a contractor pulls the chart. These reviews are not random; UPIC and MAC auditors target TMS specifically and read for the numeric motor threshold, the standardized rating scales, and a documented diagnosis. A 600-word note that's missing the pulse count fails the same review a complete 200-word note would pass. A single recoupment on a full course can run well into five figures.
We read every claim against the documentation the LCD and the plan require. The numeric motor threshold, pulse count, coil position, stimulation parameters, and failed-trial history, and flag anything missing while the note can still be corrected. We also watch the company a TMS clinic keeps on a claim, since billing an add-on like the 90836 psychotherapy code alongside 90868 raises audit odds on its own.
Deep TMS, theta-burst, or an accelerated protocol gets delivered as if it pays like standard rTMS. It often doesn't. Aetna classifies accelerated TMS as investigational outside an IRB-approved trial, and several 2026 commercial policies now require the device and protocol named on the claim. When that detail is missing or the protocol isn't covered, the denial arrives after the course is already underway and the revenue is committed.
We confirm device and protocol-specific coverage with the plan before the first session. We separate the covered protocols from the ones a given payer still treats as investigational. We name the device and protocol on the claim wherever a 2026 policy asks for it.
Everything our team does as TMS billing service keeps the TMS course authorized and coded in focus to make sure it pays clean and stays paid.
We file the authorization to the plan’s medical-necessity criteria and track it against the approved session count. Since carrier review runs five to fourteen business days and a course can’t wait. When a request is denied, we take it to peer-to-peer review, the appeal route that overturns a well-prepared clinical case most often. We start the renewal early enough that treatment never pauses between authorizations.
We bill 90867 once for the mapping session, 90868 for the daily treatments, and 90869 only on a true re-determination. We keep the units matched to the sessions on record. Each claim goes through same-day and once-per-course edit checks before it goes out. We apply modifier 25 to the E/M code rather than risk the bundle where a same-day E/M service is genuinely separate.
Before treatment starts we confirm the plan covers TMS, what the patient owes across a 30 to 36 session course, and whether the specific device and protocol are covered. We separate network status from the benefit itself, because a covered service delivered out of network still pays like an out-of-network claim, and that surprises clinics after the fact.
We read each claim for the data a UPIC or MAC reviewer looks for. The data contains numeric motor threshold, pulse count, coil position, and failed-trial history. Because these audits target TMS rather than sample it at random, the standard we hold a note to is the one a reviewer would apply.
We work aging AR and rework denials, including medical-necessity and peer-to-peer appeals, then trace each denial to its cause so the same one stops recurring. Our team has structured a full denial methodology for denial management
We verify the provider’s device-manufacturer training, file the payer enrollment. Some procedures expect the physician to personally perform the 90867 and 90869 work while a certified technician delivers 90868. We confirm the supervision arrangement according to the requirements. The full enrollment workflow is on the credentialing and enrollment page.
A TMS course has more failure points than a standard office visit and far more money riding on each one. The authorization, the code edits, and the documentation all have to hold, and because a full course is worth thousands rather than a single visit’s fee, one denied or recouped course is a real loss rather than a rounding error.
A biller who works TMS every day already knows which payers treat accelerated protocols as investigational, which require the device named on the claim, and which dropped prior authorization in 2026 without changing the medical-necessity standard underneath. Clinics find that a percentage of collections costs less than carrying that expertise in house, and when they add a device or a new TMS line, the credentialing comes with it.
Not sure your TMS course is coded and authorized correctly? An audit finds the gap before the payer does.
90867 is the initial session. 90868 is the routine daily session and the workhorse of the course. 90869 covers an occasional motor-threshold re-determination. Our certified coders know the split right between them, and respect the once-per-course and same-day rules. It is the difference between a course that pays and one that recoups.
| Service | What We Handle |
|---|---|
|
90867 Once per course |
Initial session: Cortical mapping, motor-threshold determination, and the first treatment delivery. Billed once per treatment course and not on the same day as 90868 or 90869. Medicare’s coverage article holds it to once per patient per episode and not more than once in a six-week period. A new course can be billable for a new distinct depressive episode after remission, with medical necessity documented. |
|
90868 Most sessions |
Routine subsequent session: Cortical mapping, motor-threshold determination, and the first treatment delivery. Billed once per treatment course and not on the same day as 90868 or 90869. Medicare’s coverage article holds it to once per patient per episode and not more than once in a six-week period. A new course can be billable for a new distinct depressive episode after remission, with medical necessity documented. |
|
90869 Occasional only |
Routine subsequent session: Used only when the motor threshold is re-assessed during the course, for example after a medication change, a shift in response, or a treatment gap. It replaces 90868 for that one session. It is not the routine code, and it cannot be billed on the same day as 90867 or 90868. |
We bill TMS in all 50 states. The multi-state piece is the hard part, because TMS coverage and prior-auth rules vary by state plan and Medicaid program, and a clinic running across state lines is tracking several rulebooks at once. We carry that for you. Each state below leads with the dominant commercial plan and the TMS nuance worth naming.
California
Texas
Florida
New York
Pennsylvania
Ohio
Georgia
North Carolina
Michigan
New Jersey
Washington
Arizona
Massachusetts
Virginia
Colorado
Tennessee
Clinic in a metro and searching for TMS billing nearby? We work with practices in New York City, Los Angeles, Chicago, Houston, Dallas–Fort Worth, Phoenix, Philadelphia, San Diego, Miami, Atlanta, Boston, Seattle, Denver, Washington DC, the Bay Area, Las Vegas, Charlotte, Nashville, Austin, and Tampa.
Prior authorization, where most payers want approval before the first session. Medical necessity, built on documented failed antidepressant trials and a covered diagnosis. And documentation, the set of values that survives a payer audit. You get paid when you do these three correctly, but if you miss one, you end up with denial or recoupment.
Authorization has long been the gate on a TMS course, and payers still want it secured before the first treatment. The landscape is moving: one major behavioral health plan dropped the prior-auth requirement for in-network providers in 2026. That does not remove the work. Eligibility, network status, and the medical-necessity record all still have to be confirmed before treatment, and out-of-network providers under the same plan still need authorization.
Coverage rests on treatment-resistant depression, shown through documented failed antidepressant trials or a documented intolerance to medication. The core covered diagnoses are recurrent major depressive disorder (ICD-10 F33.x) and severe single-episode MDD (F32.x). OCD (F42) is covered for FDA-cleared OCD devices, though some Medicare contractors have found the OCD evidence insufficient, so it varies. Anxiety alone, such as F41.1, is generally not covered as a stand-alone TMS indication and denies at nearly every major payer.
The record needs the numeric motor threshold, the pulse count, coil positioning, the stimulation parameters, the failed-trial count, and informed consent. The single most common audit and recoupment trigger is a missing numeric motor threshold paired with thin failed-trial documentation.
TMS is delivered in person at the clinic. It is not billable as telehealth, and it is not a group service. The place of service is the office. A claim that mis-codes the place of service invites a denial that never needed to happen.
Prior authorization
90867 frequency
90868 vs 90869
Documentation
Device coverage
Telehealth
Pricing
The relationship starts with a free TMS billing audit and you see what we find before you commit to anything. We get paid when you get paid, which keeps the incentive on clean, collected claims rather than volume.
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Our audit finds the problem in under 48 hours, with no commitment.
TMS billing uses three CPT codes. 90867 is the initial session, which covers cortical mapping, motor-threshold determination, and the first treatment delivery. 90868 is the routine subsequent session billed for most of the course. 90869 is the subsequent session with a motor-threshold re-determination. The three codes cannot be billed together on the same day.
CPT 90867 is the initial TMS session, with cortical mapping, motor-threshold determination, and the first delivery, billed once per treatment course. CPT 90868 is the routine subsequent session billed for most of the 30-to-36 visits in a course. CPT 90869 is used only when the motor threshold is re-determined mid-course. 90867 cannot be billed on the same day as 90868 or 90869.
Once per treatment course. 90867 covers the patient-specific setup and calibration that happens only at the start. Medicare's coverage article holds it to once per patient per episode and not more than once in a six-week period. A new course can be billable for a new distinct depressive episode after remission, when medical necessity is documented.
No. 90867 is mutually exclusive with both 90868 and 90869 on the same date of service. The CCI edits carry a modifier indicator of zero, which means the codes cannot be unbundled under any modifier. Billing them together produces a denial on the second code every time.
For most payers, yes, and authorization should be secured before the first session. The picture is shifting: one major behavioral health plan dropped the requirement for in-network providers in 2026. Even then, eligibility, network status, and the medical-necessity record still have to be confirmed, and out-of-network providers under that plan still need authorization.
The record needs the numeric motor threshold, the pulse count, coil positioning, the stimulation parameters, the failed medication trial count, and informed consent. The single biggest audit and recoupment trigger is a missing numeric motor threshold paired with thin failed-trial documentation. Completeness matters more than length.
Yes, for severe major depressive disorder under local coverage determinations. Medicare's threshold is one failed antidepressant trial in the current episode, or documented intolerance, which is lower than most commercial plans. A psychiatrist's order after a face-to-face exam is required, treatment runs under direct supervision, and OCD has generally been found non-covered by Medicare contractors.
A standard course runs 30 to 36 sessions over four to six weeks, with each session lasting roughly 20 to 40 minutes. In billing terms that is one unit of 90867 at the start and the remaining sessions as 90868, with 90869 appearing only on the rare session where the motor threshold is re-checked.
No. TMS is delivered in person at the clinic and is not billable as telehealth. It is also not a group service. The place of service is the office, and mis-coding it is an avoidable cause of denial.
Deep TMS and theta-burst bill within the same 90867 to 90869 family as standard rTMS. The difference is coverage and documentation. Some 2026 payers, including major commercial plans, now want the device and protocol named on the claim, and some treat accelerated protocols as investigational. We verify device- and protocol-specific coverage before the course.
Payers commonly require provider training on the specific TMS device. A qualified provider, a physician or a PMHNP or PA with TMS training, supervises the course, with the mapping and motor-threshold work done by a qualified provider. The practice and provider must be enrolled and the TMS service recognized by the payer before the first claim.
The common causes are a missing or incomplete prior authorization, code errors across the 90867 to 90869 family, and documentation gaps, especially a missing numeric motor threshold or failed-trial history. A claim can pay and still recoup months later if the chart does not support it on audit. Unqualified staff performing mapping without supervision is another trigger.
We work on a percentage of collections, so we are paid when you are paid. There are no setup or software fees, and the first step is a free TMS billing audit before any commitment. Specific percentages depend on your volume and payer mix. [VERIFY pricing terms with client before publishing.]
Yes. We integrate with the practice EHR and build the same-day and once-per-course edit prompts into the workflow, so the coding and documentation checks happen where your team already works. The setup is HIPAA compliant and runs remotely.
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info@mentalhealthbillingservice.com
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