CPT code 90868: Billing guide for subsequent TMS therapy sessions

Key Takeaways

CPT code 90868 describes therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session – reported for every follow-up TMS session after the initial 90867 intake.

ICD-10 codes F32.1, F32.2, F33.1, and F33.2 (major depressive disorder, moderate to severe, without psychosis) are the primary medical necessity codes accepted by CMS and most commercial payers.

Prior authorization requirements vary significantly by payer: Highmark requires authorization for 90868 effective May 2026, while New Mexico Medicaid does not require prior authorization for TMS services.

Pabau’s claims management software and AI-assisted clinical documentation tools help psychiatry and mental health practices streamline TMS billing workflows and reduce claim errors across the 90867-90869 code family.

CPT code 90868 is the billing code for each subsequent transcranial magnetic stimulation (TMS) treatment session – the delivery and management of a follow-up session after the initial 90867 intake. It is reported once per session across a treatment course that typically runs 20 to 36 sessions. The mental health EMR you use to document and submit those sessions determines how consistently each claim meets payer criteria.

This guide covers CPT code 90868 in full: what it describes, how it fits within the 90867-90869 TMS code family, which ICD-10 codes establish medical necessity, what documentation each session requires, and how payer policies differ for Medicare, Medicaid, and commercial insurers.

CPT code 90868: definition and clinical description

CPT code 90868 is the standard billing code for each subsequent TMS treatment session after the initial setup. The official AMA descriptor, as maintained by the American Medical Association, reads: “Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session.”

The “per session” designation is critical. A standard MDD treatment course typically involves 20 to 36 sessions over four to six weeks, and 90868 is reported once for each of those sessions. Providers must not bill a single 90868 for multiple sessions delivered on the same day, even if the patient receives two separate stimulation protocols.

TMS is an FDA-cleared non-invasive neuromodulation therapy. A focused magnetic field, delivered through a coil positioned against the scalp, stimulates neurons in the left dorsolateral prefrontal cortex – the region most consistently implicated in treatment-resistant depression. The therapy requires no anesthesia and is delivered in an outpatient or office setting.

The 90867-90868-90869 TMS code family

CPT code 90868 makes sense only in context of the full three-code TMS family. Each code represents a distinct phase of the treatment series.

A practical note on specialty behavioral health CPT codes: 90868 cannot be billed for a session that also involves motor threshold re-determination. On those specific sessions, you must report 90869 instead. Attempting to bill 90868 for a re-determination session is one of the most common coding errors in TMS practices.

Per payer policy guidance, subsequent TMS codes (90868 or 90869) should not be billed without a prior initial session documented under 90867 in the treatment series. If a patient transfers mid-series from another provider, document the transfer clearly and retain records of the originating 90867 session.

ICD-10 codes that support CPT code 90868

According to CMS Medicare Coverage Database Article A57072, the following ICD-10-CM codes support medical necessity for CPT codes 90867, 90868, and 90869. Documentation of the depression screening that established the diagnosis – for example, a positive screen reported with HCPCS code G8431 – strengthens the record. Submitting 90868 with an unsupported diagnosis code is the primary cause of preventable denials.

Anxiety-spectrum codes (F40.x, F41.x) do not support medical necessity for 90868 under most LCD policies. Patients with comorbid anxiety and MDD should be coded to the primary condition driving the TMS treatment – typically one of the moderate-to-severe depression ICD-10 codes listed above. Related codes such as F32.9 (major depressive disorder, single episode, unspecified) do not meet the specificity 90868 requires, so confirm the accepted diagnosis against the LCD for your MAC jurisdiction.

OCD as a TMS indication requires separate consideration. The FDA cleared deep TMS for OCD, but payer coverage of 90868 under an OCD primary diagnosis (F42.x) is inconsistent. Verify with each individual payer before submitting; some commercial plans explicitly exclude OCD as a covered indication for 90868.

Documentation requirements for each 90868 session

Each subsequent TMS session billed under CPT code 90868 requires a session-specific treatment note. A blanket note covering multiple sessions, or copying and pasting the same note without modification, is a documented audit risk. Payers expect the record to reflect what actually happened during that session.

The note should include the following elements for each 90868 session:

• Session date and duration: exact start and end time or total stimulation time
• Coil positioning: location (typically left DLPFC), angle, and distance from scalp
• Stimulation parameters: frequency (Hz), pulse intensity (expressed as a percentage of motor threshold), number of pulses, and inter-train interval
• Patient tolerance and feedback: any adverse effects (headache, scalp discomfort, syncope), patient-reported experience, and clinical observations
• Motor threshold reference: the most recently determined motor threshold value and the date it was established (under 90867 or a subsequent 90869)
• Provider attestation: supervising or treating physician or qualified non-physician practitioner signature

Practices using a psychiatric evaluation template as a starting point for TMS session notes should customize the template to capture the stimulation parameters listed above. A structured SOAP note for mental health works well for the per-session record, while a standardized psychiatry intake form captures the baseline history at the start of a series. Generic psychiatric progress notes are insufficient for TMS billing. Digital intake forms configured specifically for TMS session documentation help standardize this process across providers and reduce the risk of incomplete records at audit time.

For practices dealing with the documentation burden across 20-plus sessions per patient, AI-assisted clinical documentation can reduce the time required to generate compliant session notes without sacrificing the specificity that payers require.

Reimbursement rates and the CMS fee schedule for CPT code 90868

Medicare reimbursement rates for CPT code 90868 are set annually through the CMS Physician Fee Schedule. Rates vary by geographic locality and are adjusted by the geographic practice cost index (GPCI) for each MAC region.

To find the current national average and locality-specific rates for 90868, use the CMS Physician Fee Schedule lookup tool, filtering by CPT code 90868 and your practice’s MAC region. The same CMS data files publish the work RVU values for 90868, so you can confirm both the fee and the RVU components from a single source.

Commercial payer rates for 90868 typically negotiate above Medicare rates, though the spread varies considerably by region and plan. Some larger commercial payers base reimbursement on a percentage of the Medicare fee schedule (often 110-130%), while others use contracted rates established at credentialing.

Place of Service (POS) code matters for reimbursement. Most TMS services are delivered in an outpatient office (POS 11) or independent clinic (POS 49) setting. Hospital outpatient department settings carry different facility fee structures and should be billed under the appropriate outpatient facility codes rather than the professional fee schedule rate.

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Insurance coverage and payer policies for 90868

Coverage for CPT code 90868 is established but not uniform. Medicare, Medicaid, and commercial payers each maintain their own policies, and prior authorization requirements differ widely.

Medicare

Medicare covers 90868 for MDD under the applicable Local Coverage Determination (LCD) for TMS, with CMS Article A57072 governing billing and coding guidance. Coverage requires documentation of treatment-resistant depression – specifically, an inadequate response to one or more antidepressant medications at adequate doses and duration during the current episode.

Medicaid

State Medicaid coverage for TMS is expanding. California’s Medi-Cal program added CPT codes 90867, 90868, and 90869 as covered benefits effective July 2024, per a DHCS bulletin. New York State Medicaid extended coverage for the same codes effective November 1, 2025, specifically for treatment-resistant MDD. New Mexico’s Medicaid program does not require prior authorization for TMS services under these codes, per draft HCA guidance from February 2024.

Coverage in other states varies. Verify with your state Medicaid agency or MAC before billing 90868 to Medicaid in states not listed above. For practices that treat conditions outside MDD, note that TMS coverage for non-MDD indications is even more variable at the state Medicaid level; choosing the right platform matters, and our guide to the best EHR software for mental health covers what to look for.

Commercial payers

UnitedHealthcare maintains a published medical policy for TMS that covers 90868 for MDD with treatment-resistant documentation. Highmark includes CPT code 90868 in its list of procedures requiring prior authorization, effective May 1, 2026, under the Highmark Behavioral Health and TMS category. Practices billing Highmark for TMS should confirm authorization is in place before initiating subsequent sessions.

The psychiatry EMR software your practice uses should allow you to flag authorization requirements by payer at the patient level, so billing staff can track authorization status across multi-week TMS treatment series without relying on manual spreadsheets. For a wider view of how these systems fit a behavioral health workflow, see our overview of psychiatry EHR platforms.

Common billing errors and denial patterns for CPT 90868

TMS billing denial patterns are predictable once you know what payers flag. The most frequently cited issues for 90868 claims include the following.

• Unsupported ICD-10 code: billing 90868 with an anxiety or PTSD diagnosis code when the payer’s LCD requires an MDD code. Always verify the specific F32.x or F33.x code accepted before submission.
• Missing prior authorization: many commercial payers require authorization for subsequent TMS sessions, not just the initial series approval. Confirm whether authorization covers all sessions or only a specific count.
• Bundling errors: NCCI (National Correct Coding Initiative) edits govern what can be billed alongside 90868. An E/M code billed on the same day as 90868 may be bundled unless a significant, separately identifiable service is documented with modifier 25 appended to the E/M code.
• Copy-paste documentation: identical session notes across multiple dates of service trigger medical review. Each 90868 session note must reflect actual observations from that specific session.
• 90868 vs. 90869 confusion: billing 90868 on a session where motor threshold was re-determined. Use 90869 on those specific dates and reserve 90868 for standard subsequent sessions.
• Telehealth billing: TMS is a hands-on neuromodulation procedure and cannot be billed via telehealth codes. Ensure 90868 is never submitted with a telehealth modifier or place-of-service code 02.

Using claims management software with built-in claim scrubbing helps catch these errors before submission. A system that flags payer-specific rules – including NCCI edits for 90868 – reduces the volume of remits your billing team needs to work after the fact.

For ADHD screening CPT code documentation practices that also provide TMS, note that ADHD is not a covered TMS indication under most payer policies, and billing 90868 alongside ADHD-focused encounter codes may trigger additional scrutiny.

Related CPT and HCPCS codes used alongside 90868

TMS practices often need to understand which adjacent codes interact with 90868 in billing and NCCI edit contexts.

A procedure-to-diagnosis crosswalk that includes LCD and LCA policy data can help verify which diagnosis codes are accepted for 90868 by your MAC. This is particularly useful when treating patients with comorbidities who may qualify under multiple potential ICD-10 codes.

For a coding reference specific to CPT code definitions and modifiers, the AAPC Codify CPT lookup provides the current AMA descriptor alongside modifier guidance and crosswalk data for the 90867-90869 family.

Conclusion

Getting CPT code 90868 right across a full TMS treatment series requires consistent session-level documentation, accurate ICD-10 diagnosis coding, and payer-specific authorization tracking – none of which can be managed effectively with a manual process at scale.

Pabau’s claims management tools and automated workflows help psychiatry and mental health practices build the documentation and billing infrastructure TMS programs need. See how Pabau handles subsequent session billing by booking a demo.

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