TMS Billing Guide: CPT 90867–90869, Prior Authorization, and Why Courses Get Denied Mid-Treatment

Transcranial magnetic stimulation can be clinically straightforward once a patient begins treatment, but the billing process is often anything but straightforward.

A TMS course can involve weeks of scheduled treatment, multiple procedure codes, payer-specific medical-necessity requirements, authorization limits, medication-history documentation, motor-threshold re-determination, and ongoing psychiatric management.

That creates an unusual revenue-cycle risk.

A patient may be approved for TMS, successfully begin treatment, and then have claims denied several weeks into the course.

The problem is not always that TMS itself is non-covered. Often, something changed between the original authorization and the claim being submitted: authorized units were exhausted, the authorization period expired, the wrong TMS code was used, a re-determination was billed incorrectly, the servicing provider did not match the authorization, or the medical record no longer supported what the payer expected.

For psychiatry practices, the important question is therefore not simply.

“Was TMS authorized?”

It is:

“Does every treatment delivered remain aligned with the authorization, coding rules, documentation, provider information, and remaining approved units?”

That distinction can determine whether an entire course pays cleanly or develops a denial problem halfway through treatment.

Important: TMS coverage and authorization rules vary significantly by payer, plan, Medicare Administrative Contractor, state, diagnosis, device, and benefit design. This article is educational and should not replace current payer policy, CPT guidance, contractual requirements, or individualized coding advice.

Understanding CPT 90867, 90868, and 90869

Three CPT codes form the core of repetitive TMS billing.

CPT code Practical role in the TMS course 90867 Initial TMS treatment, including the initial mapping/motor-threshold work and treatment delivery 90868 Subsequent routine TMS treatment session 90869 Subsequent motor-threshold re-determination with treatment

The distinction matters because these codes are not interchangeable.

CMS guidance states that 90867 is generally reported once during a treatment course. Medicare coding guidance also states that 90867 should not be reported together with 90868 or 90869 for the same encounter, and some Medicare policies restrict repeat reporting of 90867 within a six-week period.

CMS also states that 90868 and 90869 are not timed codes and generally should be reported as one unit per day.

The simplest way to think about the sequence is:

Start of course → 90867

Routine subsequent treatment → 90868

Later treatment requiring a new motor-threshold determination → 90869

That sounds simple, but problems begin when the clinical workflow and billing workflow are not synchronized.

For example, if the clinical team performs a routine session but the claim is submitted as a motor-threshold re-determination, or if 90867 is mistakenly repeated as though it were a routine treatment code, the claim may not match coding or payer utilization rules.

CMS specifically states that 90869 should not be reported together with 90867 or 90868 for the same service date under applicable Medicare guidance.

This is why TMS coding should follow the actual clinical event, rather than simply copying the code used on the previous claim.

Prior Authorization Is More Than an Authorization Number

Many TMS practices treat authorization as a one-time front-end task.

The team obtains an approval, records the authorization number, and schedules treatment.

But a usable TMS authorization contains much more information than a confirmation number.

The practice needs to understand exactly what was approved.

That can include the covered diagnosis, treatment codes, number of approved units, authorization start and end dates, rendering provider, servicing location, frequency, whether retreatment is permitted, and whether additional clinical review is required during the course.

Commercial and government payer requirements vary significantly.

For example, current Medicare LCDs can differ in their treatment-resistance requirements. Some Medicare contractor policies cover severe major depressive disorder after failure or intolerance of one or more appropriate pharmacologic trials, while another Medicare LCD includes additional requirements such as an unsuccessful course of evidence-based psychotherapy.

Commercial criteria can be substantially different again. An Anthem TMS authorization form, for example, requests detailed information regarding medication trials, dose, duration, outcome, standardized depression-rating scores and psychotherapy history.

That is why a practice should never build one universal “TMS authorization checklist” and assume it applies to every payer.

The correct workflow begins by checking the patient's specific plan and the payer policy in effect for the requested date of service.

Anthem itself cautions that medical policies, benefit contracts and authorization requirements can differ and directs providers to verify authorization requirements for the particular member and plan.

Medication History Is Often the Foundation of the Authorization

One of the most important components of a TMS authorization request is documenting treatment resistance.

Saying that a patient has “failed medications” is often not enough.

The record may need to establish exactly what medication was attempted, the dose, how long the patient remained on it, whether the patient adhered to treatment, what clinical response occurred and, when applicable, what adverse effect made continued treatment intolerable.

Some payer forms specifically request these details. Anthem's authorization documentation, for example, includes fields for medication, trial dates, maximum dose, duration and the outcome of the trial.

Medicare contractor policies similarly describe a failed medication trial in terms of an adequate medication dose and duration, although the exact requirements differ by jurisdiction.

This means the authorization team should not be reconstructing the medication history on the day the request is submitted.

The information should already be structured in the clinical record.

A strong TMS authorization file connects the patient's diagnosis, symptom severity, medication history, psychotherapy history where required, standardized assessment scores, psychiatrist evaluation and requested treatment course into one consistent clinical story.

When these pieces contradict one another, the authorization becomes harder to defend.

The Authorization Is Approved. Why Do Claims Still Deny?

This is where many practices become frustrated.

The patient was approved.

Treatment started.

Several claims may even have paid.

Then suddenly a later session denies.

That can happen because authorization is not a blanket guarantee that every future claim will be payable.

The payer still compares each submitted service against the authorization, coverage rules, claim information and medical record.

CMS's standardized adjustment reason codes illustrate several authorization-related problems that can affect claims. They include missing authorization, exceeding authorization, an authorization that does not apply to the billed service, an authorization that does not apply to the provider, and an authorization whose time period has expired.

In practical TMS operations, the most common mid-course problems include:

• The practice reaches the authorized unit limit but continues treatment.

• The authorization expires before the last scheduled session.

• The authorization covered 90868 but the practice bills another TMS code that was not included.

• 90867 is incorrectly repeated later in the course.

• A motor-threshold re-determination is billed incorrectly.

• The authorization was obtained under one provider or facility, while the claim is submitted under another.

• The patient's insurance coverage changes during treatment.

• The payer requests additional clinical documentation but does not receive adequate records.

• The planned taper, extension or retreatment falls outside the originally authorized course.

• A claim is submitted without the authorization number or with information that does not correspond to the approved case.

CMS identifies CARC 197 for an absent precertification/authorization, CARC 198 when authorization has been exceeded, and other codes for authorization/provider/service mismatches and expired authorization periods.

These denials are often preventable.

The problem usually begins days or weeks before the denial appears on the remittance advice.

Track Authorized Units Before Every TMS Session

A TMS authorization should be treated like a declining balance.

Every completed treatment consumes part of what was approved.

If the practice only discovers that the authorization has been exhausted when the payer denies the claim, the revenue-cycle process is already too late.

The better approach is to maintain a live authorization tracker containing the authorization number, approved CPT codes, approved units, effective dates, rendering provider, service location, treatments completed, units remaining and the date when another utilization review or extension request should begin.

The tracker should be updated from actual completed sessions, not just scheduled appointments.

Canceled visits, rescheduled treatments, motor-threshold re-determinations and changes to the course can otherwise cause the billing team's count to diverge from the clinical team's count.

A simple control can prevent a large problem:

Before the next TMS session is delivered, the team should know exactly how many authorized units remain.

That is especially important near the end of the acute course or when a psychiatrist decides that additional treatment may be clinically appropriate.

The clinical decision and authorization decision are separate.

A psychiatrist may determine that continued TMS is appropriate, but the billing team still has to establish whether the additional treatment falls within the existing authorization or requires a new request.

Motor-Threshold Re-Determination Needs Its Own Workflow

CPT 90869 is used when a subsequent treatment involves motor-threshold re-determination.

It should not become a routine substitute for 90868.

The clinical record should support why the re-determination occurred and that the service billed corresponds to what actually happened.

CMS coding guidance states that 90869 should not be billed in conjunction with 90867 or 90868 for the same service, while current NCCI guidance limits 90869 to one unit per day.

From an operational perspective, this requires communication between the TMS technician, psychiatrist and billing team.

If the technician documents that the threshold was re-established but the billing team is never notified, the wrong code may be submitted.

The reverse is also dangerous: billing 90869 simply because the treatment parameters changed without documentation supporting the service described by that code.

The claim should follow the clinical record—not assumptions made downstream.

Why Documentation Still Matters After Authorization

An approved authorization does not eliminate the need for strong documentation.

CMS states that medical records must support the diagnosis and the procedure being billed. Medicare TMS guidance also requires documentation supporting physician involvement and evaluation of contraindications in applicable circumstances.

Think of authorization and claim documentation as two different questions.

Authorization asks:

“Can this patient receive the requested course?”

The claim asks:

“Was this specific service medically necessary, performed, documented and billed correctly on this date?”

Both have to work.

A perfectly approved treatment course can still generate claim problems when documentation is incomplete or inconsistent.

Coordinating the Psychiatrist's E/M Visits With TMS

This is another area where practices need to be careful.

Patients receiving TMS may also require genuine psychiatric evaluation and medication-management services during the treatment course.

That does not automatically mean an E/M service should be billed every time the psychiatrist checks on the patient.

The work included in the TMS service should not simply be repackaged as a separate office visit.

CMS explains that when an E/M service occurs on the same day as another procedure, modifier 25 may be appropriate when the E/M work is significant and separately identifiable from the procedure. Documentation must support that additional service.

For a TMS practice, that means the chart should clearly distinguish between routine management inherent to the TMS treatment and a separate psychiatric E/M encounter.

For example, a psychiatrist may perform a separately necessary medication-management visit, evaluate a meaningful change in psychiatric status or address another clinical issue requiring independent assessment and management.

When that occurs, the documentation should make the separate medical necessity and work clear, and the billing team should check the payer's coding and reimbursement rules before submitting both services.

The safest approach is not:

“TMS patient saw psychiatrist, therefore bill an E/M.”

It is:

“Was a separately identifiable, medically necessary E/M service actually performed and adequately documented?”

That distinction matters during audits and payer review.

What To Do When TMS Is Denied Mid-Course

The first response should not automatically be an appeal.

First determine why the claim denied.

An authorization-number error needs a different response from an exhaustion of authorized units. A coding error needs a different response from a medical-necessity denial. A provider mismatch needs a different response from an expired authorization.

If the claim itself is wrong, a corrected claim may be appropriate.

If the payer has the wrong authorization information attached to the claim, the practice may need reconsideration or claim reprocessing.

If additional treatments were medically necessary but were outside the authorized course, the practice may need an extension, additional authorization or, where permitted, retrospective review.

If medical necessity is disputed, the appeal packet should connect the psychiatrist's evaluation, diagnosis, treatment history, medication trials, psychotherapy history when required, standardized rating scales, prior response to therapy, authorization history, treatment dates and relevant payer policy.

Do not send a generic appeal letter without first identifying the payer's actual reason for denying the service.

A strong appeal addresses the exact issue the payer raised.

The Most Important TMS Billing Control Is Not in the Claim

Many TMS revenue problems originate before the claim exists.

The claim simply exposes them.

If a practice waits until an ERA arrives to discover an exhausted authorization, incorrect unit count or expired treatment window, it is managing the revenue cycle from the back end.

TMS works better when the authorization team, clinical team and billing team share the same course-level information.

Before treatment begins, the practice should confirm the payer's coverage criteria, obtain the authorization and document exactly what was approved.

During treatment, completed sessions should be reconciled against authorized units.

Before a motor-threshold re-determination, the clinical documentation and coding implications should be understood.

Before the authorization window or units run out, the team should identify whether an extension is necessary.

And when psychiatric E/M care occurs during the TMS course, it should be evaluated independently for medical necessity and coding rather than automatically bundled into—or separated from—the TMS service.

That is how a practice keeps an approved TMS course from becoming a denial problem halfway through treatment.

A Better TMS Revenue-Cycle Workflow

The best-performing TMS billing process connects four functions that are too often separated:

Clinical documentation → prior authorization → treatment tracking → claims and denial follow-up.

When those functions operate independently, small inconsistencies compound.

The psychiatrist documents one treatment plan.

The authorization team requests another number of sessions.

The TMS team follows the clinical schedule.

The billing team submits what appears in its charge queue.

The payer is the first party to discover that the pieces do not match.

For a multiweek service such as TMS, the goal should be to find those discrepancies internally before the payer does.

Need Support With TMS Billing, Eligibility, Prior Authorization or A/R?

Capitol Medical Technologies supports psychiatry and behavioral-health practices with front-end and back-end revenue-cycle workflows, including eligibility and benefits verification, prior authorization tracking, medical billing, denial follow-up and aging A/R.

For practices offering TMS, the objective is not simply to get the first authorization approved. It is to keep the authorization, documentation, treatment course and claims synchronized from the first mapping session through the final authorized treatment.

Capitol Medical Technologies
571-410-3703
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