TMS billing has three codes. That part takes ten minutes to learn. What actually costs clinics money is coverage, and coverage criteria differ so sharply between payers that the same patient can qualify under one plan and be denied outright under another.
Here are the codes, the gap that causes most denials, and where the newer protocols currently stand with the major payers.
The three codes
| Code | Descriptor | When you use it |
|---|---|---|
| 90867 | Therapeutic repetitive TMS treatment; initial, including cortical mapping, motor threshold determination, delivery and management. | Once, at the start of a course. |
| 90868 | Therapeutic repetitive TMS treatment; subsequent delivery and management, per session. | The workhorse. Every ordinary treatment session. |
| 90869 | Therapeutic repetitive TMS treatment; subsequent motor threshold re-determination with delivery and management. | When you re-determine motor threshold mid-course. |
Two things follow from the descriptors themselves. 90867 already contains the mapping and the threshold determination, so billing a separate mapping charge alongside it is duplicate billing. And 90869 is not a second initial session. It covers re-determination during an existing course, which is why payers look closely when it appears more than once or twice in a course.
The gap that causes most denials
This is the part worth reading twice, because it is where clinics lose revenue on patients they have already treated.
Medicare does not set TMS criteria nationally. They come from local coverage determinations written by the regional contractors, so yours depend on which MAC covers you. Under LCD L34522, held by First Coast Service Options and covering Florida, Puerto Rico and the US Virgin Islands, the requirement is a diagnosis of severe MDD as defined by the current DSM, and failure of one or more trials of a pharmacological medication at an adequate dose and adequate duration, or demonstrated intolerance to psychopharmacologic medications. The order must be written by a psychiatrist who has examined the patient face to face and reviewed the record. Coverage runs to an acute course of up to six weeks.
Aetna’s commercial policy asks for considerably more. For adults it requires inadequate response to two antidepressants from different classes, each at maximally tolerated dose for at least eight weeks, and augmentation therapy for at least eight weeks on top of that. The patient must be 15 or older, and a psychiatrist must have confirmed a diagnosis of severe major depressive disorder without psychosis, documented with a standardised rating scale such as the Beck or Hamilton.
Read those two side by side and the operational consequence is obvious. A patient who has failed one adequate antidepressant trial may well meet the threshold in that LCD and fall short of Aetna’s by two further requirements, one of which takes at least eight weeks to satisfy. If your intake screens against a single internal checklist, you are either turning away patients you could have treated or accepting patients whose claims will not survive review.
These are two examples, not the whole market, and even within Medicare your neighbouring state may sit under a different LCD. Medicaid adds another layer, and there the plan and the state programme can differ from each other. In California, the state reimburses TMS against a specific list of ICD-10 codes and does not require a treatment authorization request for non-specialty mental health services by default, while Anthem’s Medi-Cal managed care plan does require prior authorization through its own utilisation management team and sets a minimum age of 15. The practical answer is a screening checklist per payer rather than one for the clinic.
Session limits and retreatment
Aetna allows a maximum of 30 sessions, five days a week for six weeks, plus six tapering sessions over three weeks. Treatments beyond 36 sessions in total may be reviewed for medical necessity, on the stated basis that evidence for additional sessions is lacking.
Retreatment has its own test. Aetna requires that the patient previously achieved at least a 50 percent reduction in depressive symptoms and sustained it for at least two months, and treats retreatment within 60 days of the end of a prior course as not medically necessary.
That 60-day rule matters more than it looks. A patient who relapses at week six after finishing a course is clinically the person you most want to retreat, and is precisely the person the policy excludes. Knowing that in advance changes what you tell them at discharge.
Where accelerated TMS and theta burst stand
If you are considering an investment here, check coverage before you sign anything.
Aetna currently considers accelerated TMS experimental and investigational, and applies the same label to MRI-guided TMS, both repetitive and theta-burst, including Stanford Accelerated Intelligent Neuromodulation Therapy.
Read that boundary carefully, because it is narrower than the summaries usually suggest. Standard intermittent theta burst stimulation is not on the experimental list. Aetna’s medical necessity criteria name iTBS explicitly among the FDA-cleared modalities it will cover. What sits outside coverage is the accelerated protocols and the MRI-guided variants, not theta burst as such. Given that iTBS is now routine in most TMS practices, that distinction is worth getting right before you quote a patient.
Maintenance TMS beyond the acute protocol, and TMS for OCD and other psychiatric conditions, are also treated as experimental and investigational under the same policy. LCD L34522 likewise does not extend to OCD, and does not cover TMS for moderate rather than severe depression.
Policies move, and a device having FDA clearance is a different question from a payer agreeing to pay for it. But a clinic building a business case for accelerated or MRI-guided protocols on the assumption that commercial coverage is imminent is taking a real risk, and should price those as cash-pay until a specific payer says otherwise in writing.
Where the claims actually fail
Criteria checked once, at the clinic level. The single most expensive habit in TMS billing. Screen against the specific payer’s policy, before the first session.
Antidepressant trials not documented as adequate. Payers want dose and duration, not a list of drug names. A trial that does not evidence an adequate dose for an adequate period does not count, however clearly the patient remembers taking it.
No baseline rating scale. Where a policy requires documented severity, a note saying the depression is severe is not the same as a scored instrument. It is also what you will need to evidence the 50 percent improvement if you ever seek retreatment.
Prior authorization for fewer sessions than the course. Authorization for an initial block, then sessions continuing past it while nobody requests an extension.
90867 billed more than once. It is the initial session of a course. A second one in the same course invites a records request.
The order or diagnosis not coming from a psychiatrist. Both the Medicare LCD and Aetna’s policy require psychiatrist involvement, the LCD specifying a documented face-to-face examination and record review. This is not only a Medicare requirement.
Common questions
What are the CPT codes for TMS therapy?
Three: 90867 for the initial session including cortical mapping and motor threshold determination, 90868 for each subsequent delivery and management session, and 90869 for subsequent motor threshold re-determination with delivery and management. 90868 is the one you bill most.
How many antidepressant trials does a patient need to have failed?
It depends entirely on the payer. Under Medicare LCD L34522, held by First Coast Service Options, the requirement is failure of one or more adequate medication trials or documented intolerance, and other Medicare contractors may set it differently. Aetna requires two antidepressants from different classes at maximally tolerated doses for at least eight weeks each, plus augmentation therapy for at least eight weeks, a psychiatrist-confirmed diagnosis of severe depression without psychosis, and a minimum age of 15. Screen against the specific plan rather than a clinic-wide rule.
How many TMS sessions will insurance cover?
Aetna allows up to 30 sessions plus six tapering sessions, and treatments beyond 36 may be reviewed for medical necessity. LCD L34522 runs to an acute course of up to six weeks. Confirm the authorised session count before starting, not at session 25.
Is accelerated TMS or SAINT covered?
Aetna currently considers accelerated TMS and MRI-guided TMS, including SAINT, experimental and investigational, along with maintenance TMS. Standard intermittent theta burst stimulation is a different matter: Aetna names iTBS among the FDA-cleared modalities its medical necessity criteria cover. Coverage varies by payer and policies change, so get a written position from the specific plan before building a business case on it.
Can we retreat a patient who relapses?
Under Aetna’s policy, retreatment requires that the patient previously achieved at least a 50 percent reduction in symptoms sustained for at least two months, and retreatment within 60 days of the end of the prior course is considered not medically necessary. Keep the scored outcome measures from the first course, because you will need them.
Is TMS covered for OCD?
Not reliably. LCD L34522 covers major depressive disorder and does not extend to OCD, and Aetna considers TMS for OCD and other psychiatric conditions experimental and investigational. FDA clearance for an indication and payer coverage of it are separate questions.
The screening checklist is the revenue lever
Most TMS billing advice is about codes. The codes are three lines and you will have them memorised inside a week.
The money is in the screen. A clinic that checks each patient against their own payer’s criteria before the first session, documents dose and duration for every prior trial, records a scored baseline, and authorises the whole course rather than a block of it, will collect on nearly everything it treats. A clinic that runs one internal checklist will keep discovering the difference at week four.
It also changes your marketing. If a meaningful share of your enquiries are people who have failed one antidepressant, they may be eligible under one payer and not another, and your intake should route them differently rather than treating every enquiry as the same lead. We wrote about the related problem of consults that never convert in why your TMS consult leads don’t book, and about the capacity side in TMS chair utilization.
We are a marketing agency for mental health clinics, not a billing company. The policies cited here are examples drawn from published payer documents, linked below, and they change. Your biller and the specific plan are the authority on your own claims.
If the problem is that the chairs are empty rather than that the claims are denied, that is what we do for TMS clinics, and the growth audit is free.
Sources
CPT descriptors are the American Medical Association’s. Medicare coverage criteria from local coverage determination L34522, held by First Coast Service Options. Commercial criteria, session limits, retreatment rules and the position on accelerated, MRI-guided and maintenance TMS from Aetna Clinical Policy Bulletin 0469. California Medi-Cal ICD-10 coverage from the DHCS non-specialty mental health services guide; plan-level prior authorization and age requirements from Anthem’s Medi-Cal TMS policy update. Last reviewed August 2026.
