How to bill correctly for transcranial magnetic stimulation (TMS) in the treatment of adults with major depressive disorder
First Coast is receiving first-level appeals (redeterminations) based on claim denials for providers not including the ordering psychiatrist (MD or DO) on the claim when billing for TMS.
TMS of the brain for severe major depressive disorder (MDD), single or recurrent episode, is considered medically reasonable and necessary for up to six weeks when the following criteria are met:
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The patient has a confirmed diagnosis of severe MDD as defined by the current Diagnostic and Statistical Manual of Mental Disorders.
and
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The patient has demonstrated a failure of one or more trials of a pharmacological medication and/or demonstrates an intolerance to psychopharmacological medications as defined in the definition section above.
and
- The order for TMS procedure is written by a psychiatrist (MD or DO), who examined the patient face to face and reviewed the record.
How to avoid denials
To avoid time and cost associated with filing unnecessary appeals, submit the claim correctly the first time and be sure to include the referring or ordering provider’s name and NPI on the claim in the following locations:
- Part A claims: Block 78/79 of the UB-04 or 2420B for electronic media claims (EMC)
- Part B claims: Block 17 A and B for paper claims or 2310A or 2420F for EMC
Please review First Coast’s LCD L34522 Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder which provides coverage guidance that will help you avoid unnecessary claim denials. Within the LCD, you can also access the corresponding LCA A57647 Billing and Coding: TMS in the Treatment of Adults with Major Depressive Disorder for billing and coding guidance, including the requirement for including the ordering provider and NPI on the claim.
Additional resources
For additional assistance, access our Claims FAQs and Ordering / referring requirements for Medicare claims article for information on claim editing and how to avoid claim errors.