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TMS Billing: CPT 90867, 90868 And 90869 Explained For Psychiatry Practices

TMS billing for psychiatry practices: what CPT 90867, 90868 and 90869 cover, Medicare LCD and payer rules, authorization units and why TMS claims deny.

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TMS Billing

TMS bills on three CPT codes. 90867 is the first treatment, which includes cortical mapping and the motor threshold. 90868 is each treatment session after that. 90869 is a later session where the motor threshold gets re-determined. The Medicare billing articles we checked, from Novitas, Noridian, WPS and Wellpoint Federal, cover these codes only for severe major depressive disorder without psychotic features, F32.2 or F33.2, and commercial payers add their own medication-trial, session-count and authorization rules on top.

Bill 90867 once per course. On a re-mapping day, bill 90869 instead of 90868, never both. And count every session against the authorization the day it happens, not the day the claim goes out.

The Three Codes

The descriptions below are in our words. The official descriptors belong to CPT.

Code What It Covers How Often
90867 The initial treatment, including cortical mapping, the motor threshold determination and delivering and managing that first session Once per course. Novitas says once per episode and not more than once in 6 weeks
90868 Each later treatment session, delivery and management One per session. Evernorth allows up to two units a day
90869 A later session where the motor threshold is re-determined, plus that session’s treatment In place of 90868 that day. Evernorth allows up to two units a day

Novitas’s billing article says not to report 90869 with 90867 or 90868, and not to report 90867 with either of the others. Aetna treats one re-mapping per course as medically necessary, plus more when the patient isn’t responding or the motor threshold may have changed, like after a medication change. It also says re-mapping doesn’t add sessions, because the patient is treated during it.

Accelerated, MRI-guided theta-burst stimulation has its own Category III codes, 0889T through 0892T, and Evernorth lists them as experimental.

What Payers Require Before Authorizing

The policies we checked all start with a confirmed diagnosis of major depression and documented medication failures, and most also want a baseline score on a validated depression scale. The details differ enough to deny a claim.

Policy Medication Trials Other Requirements Course
Medicare, Novitas LCD L34998 Failure of one or more medication trials, or intolerance Severe MDD. Ordered by a psychiatrist (MD or DO) after a face-to-face exam Daily for up to six weeks
Medicare, Noridian LCD L37086 No clinically significant response to agents from at least two classes, or intolerance in two trials from two classes. A prior rTMS response or current ECT also qualifies Severe MDD. A failed trial of evidence-based psychotherapy documented with rating scales. Psychiatrist order and direct supervision 20 sessions over 4 weeks, then taper (see units below)
Aetna policy 0469 Adults need two antidepressants from two classes, at least 8 weeks each, plus augmentation for at least 8 weeks, in the current episode within the past 5 years Age 15 or older. Severe MDD without psychosis, confirmed by a psychiatrist and scored on a standardized scale. Ordered by a psychiatrist or PMHNP 30 sessions over 6 weeks plus 6 taper sessions
Evernorth EN0383 (Cigna) Adults need two or more failed trials from two classes, each at an adequate dose for at least four weeks or stopped for intolerance Age 15 or older. Moderate-to-severe MDD without psychosis. A failed psychotherapy trial. Scales at the start and end of each course 30 to 36 treatments
Optum BH803TMS112025 (UnitedHealthcare behavioral) Adults need two medication regimens from two classes that failed or weren’t tolerated Age 15 or older. A baseline validated scale. Ordered, supervised and given by a psychiatrist, or by a PMHNP in a full practice authority state 30 sessions plus 6 taper sessions

Prior authorization rules move faster than the policies. Evernorth dropped prior authorization for TMS on March 6, 2026 for its contracted providers treating Evernorth and Cigna Healthcare members. Out-of-network providers still need it, and so do network exceptions. No authorization doesn’t mean no criteria, though. EN0383 still decides what’s medically necessary, so document every case as if it will be reviewed.

For traditional Medicare, your MAC’s LCD is the rulebook, and the criteria aren’t the same from one MAC to the next.

MAC TMS LCD
Novitas L34998
First Coast L34522
Noridian L37086
WPS L34641
CGS L36469
Palmetto GBA (Part B) L34869
Wellpoint Federal (National Government Services) L33398

Authorization Units Across A Course

Aetna and Optum both cap a course at 30 sessions plus 6 taper sessions. Aetna spells it out as 30 treatments five days a week for six weeks, then 6 taper sessions over three weeks. That’s one unit of 90867 and up to 35 more sessions billed as 90868 or 90869, all drawn from the same course. Before the first session, confirm whether the payer counts sessions or units per code, and whether 90869 comes out of the same total.

Noridian’s and WPS’s Medicare billing articles split the course at week four. A patient in remission gets up to 20 sessions over 4 weeks and then 5 taper sessions. A patient who has improved at least 25% on a standard depression scale can continue for 2 more weeks, 10 sessions, plus 6 taper sessions. That’s 25 sessions on the short path and 36 on the long one, and the week-four score decides which, so record it before session 21.

Maintenance TMS isn’t covered under the Noridian, WPS and Wellpoint Federal articles, and Aetna, Evernorth and Optum all exclude it too. Retreatment runs on its own clock. Aetna wants at least a 50% reduction from the prior course that held for two months, and it won’t cover a repeat course within 60 days of the last one. Evernorth wants more than 50% improvement maintained for at least two months. Optum considers retreatment for a relapse 6 months after the most recent treatment.

Documentation That Holds Up

  • The diagnosis, coded to severity. F32.2 or F33.2 for the Medicare articles we checked and for Optum. Evernorth’s policy is written for moderate-to-severe depression, so the severity in the note has to match the code you bill.
  • Every medication trial. The drug, dose, dates, class and why it failed or was stopped. Aetna counts a trial at 8 weeks and Evernorth at four, so the dates do the work.
  • The psychotherapy trial, where the policy asks for one. Noridian and Evernorth both do.
  • Rating scale scores. A baseline in the current episode and follow-up scores on the same scale. Noridian and WPS list examples, including the PHQ-9, BDI, HAM-D, MADRS, QIDS and the Geriatric Depression Scale.
  • The order and the exam. Who ordered TMS and when they examined the patient. The Novitas and Noridian LCDs call for a psychiatrist. Aetna also accepts a PMHNP, and Optum accepts a PMHNP in a full practice authority state.
  • Contraindication screening. Novitas wants the treating physician’s judgment on absolute and relative contraindications in the pre-procedure record, and its LCD treats implanted metal or a magnetic-sensitive device within 30 cm of the coil as an absolute contraindication.
  • Each session’s record. The motor threshold, treatment parameters, device, who ran the session and who supervised it. Aetna wants the operator in the treatment room the whole time and the psychiatrist or PMHNP immediately available.
  • The ordering provider on the claim. Novitas and Wellpoint Federal require the ordering physician’s name and NPI. Novitas points to blocks 17A and 17B on paper and loop 2310A or 2420F electronically.

Why TMS Claims Deny

Each of these comes straight from the policies above.

  • A diagnosis code off the list. A moderate or unspecified depression code won’t match a Medicare article that lists only F32.2 and F33.2.
  • 90867 billed twice. A second initial code in the same course, or within 6 weeks on a Novitas claim.
  • 90869 and 90868 on the same day. Novitas says not to report 90869 with either of the other codes.
  • Sessions past the count. Session 37 on a 30-plus-6 policy, or sessions past week four on a Noridian or WPS claim without the week-four score on file.
  • The wrong ordering provider. A PMHNP order where the Medicare LCD calls for a psychiatrist, a PMHNP outside a full practice authority state on an Optum plan, or no ordering provider on the claim at all.
  • An excluded protocol. Evernorth lists theta-burst stimulation as experimental and Optum lists it as unproven, while Aetna covers intermittent theta-burst on an FDA-cleared device.
  • No authorization where one is still required. Out-of-network Evernorth claims and network exceptions still need it, and so does any plan whose own rules call for it.
  • Maintenance billed as treatment. Noridian, WPS, Wellpoint Federal, Aetna, Evernorth and Optum all exclude maintenance sessions.

Scheduling Capacity And Tracking Units

TMS fills a room the same way every weekday. On a 30-plus-6 course, a new patient comes in five days a week for six weeks and then tapers over three more, so each start holds a slot in one room for about nine weeks. The patients you can carry at once equal your rooms times the sessions each room can run in a day, and every new start needs that slot open for the whole course.

The first session carries the mapping and motor threshold work, so book it as its own slot type. Then track three things for every patient, the sessions used against the authorization, the date the authorization ends and the next rating scale due. On Noridian and WPS claims, add the week-four score.

An Automation Program can track authorization units and room schedules in your own systems for $5,000, or five monthly payments of $1,000.

TMS And Spravato In One Practice

If your practice runs both, the billing has almost nothing in common. TMS bills procedure codes per session. On Medicare, a Spravato session bills as G2082 or G2083, and both codes include two hours of observation after the dose. Each therapy needs its own authorization, its own unit math and its own documentation.

They do compete for the same rooms. A Spravato dose holds a monitored room for at least two hours, and a TMS course holds a room slot every weekday, so schedule both from one calendar of rooms. Our Spravato billing services page covers the codes, units and authorizations on that side.

Questions We Get

What Are The CPT Codes For TMS?

Three codes. 90867 is the initial treatment and includes cortical mapping and the motor threshold determination. 90868 is each later treatment session. 90869 is a later session where the motor threshold is re-determined. Bill 90867 once per course, and don't bill 90869 and 90868 for the same session.

Does Medicare Cover TMS?

Yes, through local coverage determinations, and each MAC has its own, such as Novitas L34998 and Noridian L37086. The billing articles we checked cover F32.2 and F33.2, severe major depressive disorder without psychotic features, and the LCDs require documented medication failures and an order from a psychiatrist. Maintenance sessions aren't covered under the Noridian, WPS and Wellpoint Federal articles.

How Many TMS Sessions Will Insurance Cover?

Most policies we checked allow 30 to 36. Aetna and Optum allow 30 sessions plus 6 taper sessions, and Evernorth covers 30 to 36 treatments. Noridian's and WPS's Medicare articles allow 20 sessions over 4 weeks plus 5 taper sessions, or 36 in all when the patient has improved at least 25% by week four.

Does TMS Need Prior Authorization?

It depends on the plan. Evernorth removed prior authorization for TMS on March 6, 2026 for contracted providers treating Evernorth and Cigna Healthcare members, while out-of-network providers and network exceptions still need it. Check each plan, and document to its medical policy either way, because the coverage criteria still apply without an authorization.

Can A PMHNP Order TMS?

Some payers allow it. Aetna accepts an order from a psychiatrist or a PMHNP, and Optum allows PMHNPs in states with full practice authority to order, supervise and give TMS. The Medicare LCDs from Novitas and Noridian call for an order from a psychiatrist, MD or DO.

Keep Going

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Want Your TMS Claims Worked Every Month?

Our Ongoing Billing covers TMS along with the rest of a psychiatry practice’s claims, from submission to denials, payment posting and A/R follow-up. It’s priced by practice size, from 7% of collections for a solo provider down to 4.5% for 26 or more providers, with no setup fee. The monthly minimum is $300 for a solo practice.

See Psychiatry Billing

General information, not coding or legal advice. CPT is a registered trademark of the American Medical Association. Payer policies change, so check the current version before you bill.

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