The short answer: TMS (transcranial magnetic stimulation) is billed as a course of treatment, not a single visit, and most insurers want approval before it starts. Clean TMS billing comes down to checking benefits up front, getting prior authorization before the first session, keeping every session within the approved dates, documenting each treatment, and planning for the patient's share of the cost.
Why TMS billing is different
A typical TMS course is a series of sessions over several weeks. That means one patient can generate dozens of claims, all tied to the same authorization. A problem at the start, such as a missing authorization or a benefits detail that wasn't checked, can affect every one of them.
TMS services also have their own CPT codes, covering the first treatment session (including mapping), the treatment sessions that follow, and re-checking the motor threshold during a course (90867, 90868, and 90869). Which codes apply, and how often, depends on the treatment provided and each insurer's rules.
1. Check benefits before the course begins
Before scheduling a TMS course, confirm the patient's coverage in detail:
- The patient's plan is active and covers TMS
- Whether behavioral health benefits are managed by the medical plan or a separate behavioral health company
- The patient's deductible, copay or coinsurance, and how much of the deductible is already met
- Whether the plan requires prior authorization, and what documentation it asks for
- Whether the patient has a second insurance plan
Make a copy of the front and back of the patient's insurance card and keep it in your system.
2. Get prior authorization before the first session
Most insurers require prior authorization for TMS, and it has to be approved before treatment starts. Sessions done before approval are usually denied, and they generally can't be fixed after the fact.
Plans often ask for documentation of the patient's diagnosis and treatment history, such as previous medications and therapy. Requirements vary by insurer, so check each plan's current policy before submitting.
3. Keep every session within the approved dates
An approved authorization usually covers a set number of sessions within a specific date range. Treatment has to happen within those approved dates. A session outside the window, or beyond the number of approved sessions, can be denied even though the course itself was authorized.
Do this: track each patient's approved dates and session count, and check them before every session. If a course needs more time or more sessions, ask the insurer about an extension before the approval runs out.
4. Document every session
Each TMS claim should be supported by documentation of the session that was provided. Insurers can request records, and missing or incomplete notes can lead to denials or repayment requests.
Do this: record each session consistently, including the date and the treatment provided, so the documentation always matches what was billed.
5. Plan for the patient's share
Because a TMS course includes many sessions, the patient's share of the cost can add up, especially early in the year before a deductible is met. Surprises here lead to unpaid balances.
Do this: explain the patient's estimated share before the course begins, and offer a payment plan if your clinic provides one.
Common reasons TMS claims are denied
- No prior authorization, or treatment started before it was approved
- Sessions outside the approved dates, or more sessions than were approved
- Coverage that wasn't verified, or a claim sent to the medical plan when a separate behavioral health company manages benefits
- Documentation that doesn't support the sessions billed
- Provider details on the claim that don't match the insurer's records
- Claims submitted after the insurer's filing deadline
How Becker Credentialing Services helps
TMS clinics are one of our specialties, and we have deep experience billing for TMS. Our TMS billing is handled by Stephanie Huffstetler, who has been in medical billing since 1997. We can check benefits, set up payment plans, submit claims, follow up on unpaid and denied claims, post payments, and send monthly reports.
Running a TMS clinic? Request a free billing review, and we'll talk about your practice, how you're handling billing today, and how we can help.
FAQs
Does TMS need prior authorization?
Most insurance plans require prior authorization for TMS, and it must be approved before treatment starts. Requirements vary by plan, so check each insurer's current policy when you verify benefits.
What happens if a TMS session falls outside the approved dates?
It can be denied, even if the course was authorized. Track each patient's approved dates and session count, and ask the insurer about an extension before the approval runs out.
Why do TMS claims get denied?
The most common reasons are a missing authorization, sessions outside the approved dates or session count, unverified coverage, documentation that doesn't support the sessions billed, and missed filing deadlines.