Wrapping Your Head Around Transcranial Magnetic Stimulation (TMS) Treatments and Utilization Patterns
Mental illnesses represent a major public health issue because of their prevalence in the general population. Despite advances in psychopharmacology, it is estimated that 20-30% of patients with major depressive disorders may only partially respond to pharmacological and psychotherapeutic treatment strategies.
The Transcranial Magnetic Stimulation (TMS) field has grown substantially over the past two decades, moving from promising research findings to numerous Food and Drug Administration (FDA) approved medical devices with broad ranging treatment utility in neurological and psychiatric disorders. The following table displays the approval year by the FDA for specific diagnosed conditions and includes the ICD-10 chapter and range of diagnosis codes.
| Year | FDA approved condition | ICD-10 CM chapter | ICD-10 CM code range |
|---|---|---|---|
| 2008 | Major depression | F33 | F330 to F339 |
| 2013 | Migraine headaches | G43 | G430 to G43919 |
| 2017 | Obsess compulsive disorder | F42; F60 | F420 to F429; F605 |
TMS is a non-invasive method which involves placing an electromagnetic coil on the scalp. The device produces brief pulsed magnetic fields. These rapidly alternating fields induce electrical currents within localized, targeted regions of the cortex which are associated with various physiological and functional brain changes.
This form of treatment is initiated after the patient’s major depressive episode failed to improve on at least one oral antidepressant. The course of these TMS treatments may last 4-to-6 weeks and may require prior authorization for some healthcare payers.
Coding for TMS Treatment
90867– Therapeutic repetitive transcranial magnetic stimulation, initial, including cortical mapping, motor threshold determination, delivery, and management. (Reported only once per course of treatment)
90868– Subsequent delivery and management, per session.
90869– Subsequent motor threshold re-determination with delivery and management. (Do not report 90869 in conjunction with 90867, 90868, 95860-96870, 95929, 95939)
Coding note: If a significant, separately identifiable evaluation and management, medication management, or psychotherapy code is performed, the appropriate E/M or psychotherapy code may be reported separately in addition to 90867-90869. Evaluation and management activities related to cortical mapping, motor threshold determination, delivery, and management of TMS are not separately reportable.
Considerations in Analysis
Codoxo discovered increased utilization of TMS in several of our partner’s data and suggests the following for any plan assessing their utilization and potential exposure related to TMS
- Review your individual policies for coverage criteria. Of note, Medicare coverage criteria is limited to the treatment of depression after a trial on at least one antidepressant.
- Does it specify which side of the brain this therapy is to be administered?
- Does it specify what diagnoses are covered?
- Ensure the proper credentialing to administer TMS treatment by verifying the specialties of the practitioners and their staff submitting claims for TMS. Licensed medical providers that are not practicing neurologists, psychiatrists and psychotherapists submitting claims for TMS may be performing services outside the scope of practice.
- TMS requires direct administration, supervision, and interpretation of the results by a licensed medical provider in the appropriate specialty. TMS is not eligible as an assistant at surgery procedure and cannot be performed as a supervised procedure.
- Utilization of modifier 95 that indicated the service was performed via telehealth connection would not be appropriate.
- Providers that bill evaluation and management services with modifier 25 at a consistent ratio or frequent combination each time TMS is performed should be reviewed. This scenario is especially true for those providers who combine those services at a higher percentage compared to their peers.
- Should you identify a patient with a high volume or high frequency of TMS treatments, review their history to ensure those claims comply with the treatment criteria, such as post failed or partial response to pharmacological therapy.
Identifying Potential Risk with TMS Treatments in Fraud Scope
Codoxo’s Fraud Scope Platform can assist your health plan with identifying emerging risks, trends, and outlier claims for TMS services. The AI engine and detectors identify patterns, volume, and frequency across all peer groups and claims allowing customers to pinpoint, analyze and respond to potential FWA (Fraud, Waste and Abuse) and efficacy issues.
Fraud Scope users can identify all detection reasons related to the CPT codes for TMS through the Schemes: Professional, Rendering, Top Codes widget.
Fraud Scope users can also identify utilization profiles related to the CPT codes for TMS through the Query toolkit using Professional, Aggregates, Rendering, Procedure and defining the procedure codes using These as the operator.
References:
- NIH
https://pubmed.ncbi.nlm.nih.gov/24113125/
- NIH
- Science Direct
https://www.sciencedirect.com/science/article/abs/pii/S0248866310000974
- Brain Stimulation Journal
https://www.brainstimjrnl.com/article/S1935-861X(21)00825-1/fulltext
- CMS LCD
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34998