Why TMS and ECT Claims Get Denied More Often
Title: Why TMS and ECT Claims Get Denied More Often
SEO Title: TMS Billing: Why Claims Get Denied
Meta Description: See why TMS and ECT claims may be denied and how to check authorization, place of service, coding, and provider credentials before billing.
Category: Coding & Reimbursement
Author: MCM South Billing Team
Publish Date: TBD — angle: denial-focused pain point
Transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) use procedure codes, authorization processes, and setting rules that differ from routine psychotherapy billing. TMS is reported with CPT codes 90867–90869; ECT is reported with CPT code 90870. These claims can face denial risks tied to authorization, place of service, or provider credentials. This article covers billing mechanics only. It does not address whether either procedure is appropriate for a patient.
The AMA maintains the CPT code set. Check the current code descriptors and payer rules before submitting a claim. For a broader overview, see our guide to TMS and ECT procedure billing for psychiatric practices.
TMS Billing Codes (90867–90869)
CPT 90867 generally reports the initial TMS treatment, including the required treatment setup and delivery. CPT 90868 reports a subsequent treatment session. CPT 90869 reports a subsequent session that includes redetermination of the motor threshold. Confirm current descriptors in the AMA CPT code set and follow the payer’s coding instructions.
A common denial risk is billing without confirmed prior authorization for the service and number of sessions being claimed. Another is billing 90868 or 90869 without documentation that supports the sequence of treatment, including the initial session when required. Check whether the authorization covers the date, rendering provider, location, and specific service being billed. A general authorization reference or approval for a different number of sessions may not be enough.
MCM South recommends keeping the authorization record with the billing documentation and checking the payer’s written policy before treatment begins. Requirements vary by plan. See why TMS and ECT need heavier prior authorization for a closer look at the authorization workflow.
ECT Billing Code (90870)
CPT 90870 reports electroconvulsive therapy. Before submitting, confirm that the claim’s place-of-service code—the code that identifies where the service took place—matches the actual setting and the payer’s rules.
A common ECT denial pattern is a mismatch between the submitted place of service and the facility or setting where treatment occurred. Another is missing or incomplete authorization documentation, including information the payer requires about prior treatment. Do not assume that the same place-of-service instructions apply across payers or locations. Review the plan’s policy and the place-of-service rules for TMS and ECT billing.
Why These Claims Get Extra Scrutiny
TMS and ECT claims involve procedure codes and payer review requirements that differ from routine psychotherapy claims. That does not mean every claim will be denied, and we are not claiming a specific denial rate. It means there are several details to verify before submission:
- Prior authorization: Confirm that approval applies to the billed service, date, number of sessions, provider, and setting. Many plans have procedure-specific review requirements. Learn more about prior authorization.
- Place of service: Make sure the code reflects where the procedure actually took place and matches payer instructions.
- Code and session sequence: Use the code that describes the service provided. For TMS, make sure the record supports the distinction between an initial session and a subsequent session.
- Provider credentials: Confirm the billing provider meets the payer’s requirements for the procedure and is correctly credentialed and linked to the claim.
- Supporting documentation: Keep the authorization decision, relevant service documentation, and claim details together so the practice can respond if the payer requests records.
A denial may point to a missing approval, a place-of-service mismatch, or a credentialing issue rather than a disagreement about clinical care. MCM South focuses on the billing and payer-policy side of behavioral health claims, including checking these requirements before submission.
Who Can Bill and Perform These Procedures
TMS and ECT are physician-only procedures under the scope described here. Before billing, verify the treating or supervising physician’s credentials, the payer’s provider rules, and how the payer requires the claim to identify the rendering and billing providers. Do not assume that a clinician’s general behavioral health credential automatically meets a plan’s requirements for these procedures.
For more on which clinicians may bill these services, read Who Can Bill TMS or ECT? Physician-Only Procedures. This is separate from routine psychotherapy billing, where provider eligibility and code rules may differ.
Why do TMS and ECT claims get denied?
TMS and ECT claims may be denied when prior authorization is missing or does not cover the service billed, when the place-of-service code does not match the treatment setting, or when provider credentials and claim details do not meet the payer’s requirements. For TMS, documentation that supports the billed session and its place in the treatment sequence may also matter. Check the plan’s current policy before submitting.
FAQ
What’s the most common reason a TMS claim gets denied?
A frequent billing issue is missing or incomplete authorization for the specific service or session count. A claim may also be questioned if the documentation does not support the TMS code billed, such as a subsequent-treatment code without a clear record of the treatment sequence.
What’s the most common reason an ECT claim gets denied?
A place-of-service mismatch or incomplete prior-authorization documentation can lead to a denial. Confirm the treatment setting and required supporting information against the payer’s current policy.
Can a denied TMS or ECT claim be appealed?
A practice can review the denial reason and follow the payer’s appeal or corrected-claim process when available. The response should address the specific issue the payer identified and include the requested documentation. Check filing deadlines and submission instructions in the plan’s denial notice and policy.
The Takeaway
Many preventable TMS and ECT billing problems come down to three checks: prior authorization, place of service, and provider credentials. Confirm each one before submitting the claim. Requirements vary by payer, so verify the current policy rather than relying on a past approval or a rule used for another plan.
Quick Action Checklist
- Confirm prior authorization covers the specific service, session, date, provider, and setting being billed.
- Check that the place-of-service code matches where the procedure took place and follows payer instructions.
- Verify the physician’s credentials and claim role, and make sure the documentation supports the code billed.
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MCM South Medical Billing Service, LLC has specialized in mental and behavioral health billing since 2010. We serve psychotherapists and psychiatrists in Georgia, Massachusetts, Connecticut, Texas, Florida, and New York, with billing experience across all 50 states.
