CPT code 90869 – TMS motor threshold re-determination

Key takeaways

CPT code 90869 is billed only on a TMS session where the motor threshold is re-determined, never on routine sessions.

Routine sessions, from session two to the end of the course, are billed as 90868, the highest-volume TMS code.

On a re-determination day, 90869 replaces 90868, and the two are never billed for the same session.

Expect 90869 often once or twice, or not at all, depending on the course. It usually follows a dose change, a treatment break, or a clinical need to re-measure.

Every 90869 note must record the new threshold value and the reason it was re-determined.

CPT code 90869 covers threshold re-determination days

CPT code 90869 reports a subsequent TMS session in which the clinician re-measures the patient’s motor threshold, then delivers and manages the treatment.

The AMA descriptor reads: “Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management.”

The key word is re-determination. A routine session after the first one is billed as CPT code 90868. 90869 applies only to the session where the threshold is measured again, and on that day it replaces 90868.

The three TMS codes split a course by the work done in each session, as the table shows.

A standard course typically runs 30 to 36 sessions over about six to nine weeks. Nearly all of those sessions are 90868. 90869 is the exception code, and it should appear only when documented.

When a session earns 90869 instead of 90868

The motor threshold sets the stimulation dose. When the clinician has a reason to believe it has shifted, they measure it again. That re-measurement is what turns a 90868 session into a 90869 session.

Common reasons to re-determine the threshold include:

• A dose or protocol change ordered by the treating psychiatrist.
• A break in treatment, such as missed days for illness or travel.
• A medication change that may alter cortical excitability.
• A clinical need to re-map, such as a change in the patient’s response or tolerance.

A threshold check done out of habit, with no stated reason, does not support 90869. Bill that session as 90868 and keep the note honest.

How one TMS course codes out, session by session

Take an illustrative patient on a 36-session course for major depressive disorder. The patient misses a week after session 11. Later, the psychiatrist changes a medication that can affect the threshold.

Here is how the course codes out.

The course totals one 90867, 33 units of 90868, and two units of 90869. Laid out as a timeline, the two re-determination days are easy to spot.

If the claim history showed 90869 on 30 sessions instead, an auditor would ask for 30 re-determination notes.

What a 90869 note has to prove

The re-determination is the billable difference, so the note has to show it happened and why. Copied notes that look the same as a routine session are an audit trigger.

• New threshold value: the re-determined motor threshold, with the prior value for comparison.
• Reason: the dose change, treatment break, medication change, or clinical concern that prompted it.
• Treatment delivered: coil position, frequency, pulses delivered, and the threshold used for dosing.
• Supervision: the supervising psychiatrist, as the applicable policy requires.
• Symptom tracking: rating scale scores at baseline and at regular points through the course.

A clean claim depends on that note being retrievable on request. Post-payment reviews of TMS often pull the whole course, not one date. Strong billing compliance habits from session one protect every claim in it.

Which diagnoses support medical necessity for 90869

Payers check the claim’s diagnosis against their covered list of ICD-10-CM codes for TMS. Medicare’s billing article for LCD L37086 lists only the severe, non-psychotic depression codes.

Match the code’s severity to what the psychiatrist documented for that date. Billing F32.2 when the note says moderate invites a post-payment review.

Medicare covers 90869 under LCD L37086

There is no national coverage determination for TMS. Each Medicare Administrative Contractor publishes its own LCD. Noridian’s LCD L37086 sets these core conditions:

• A psychiatrist (MD or DO) who has examined the patient writes the order.
• Treatment is given under that psychiatrist’s direct supervision.
• The patient shows treatment resistance, such as no clinically significant response to antidepressants from at least two drug classes.
• An evidence-based psychotherapy trial has not produced significant improvement on standardized rating scales.
• No exclusions apply, such as a seizure history, psychotic symptoms, or implanted metal or devices near the coil.

The companion billing article A57692 covers up to 20 visits over four weeks, plus five taper visits. Patients with at least 25% improvement may get 10 more visits over two weeks, plus six taper visits. Other MACs publish parallel LCDs, so check yours.

Get prior authorization before session one

Most commercial and Medicare Advantage plans require prior authorization for the TMS course. The authorization covers a set number of sessions, and 90869 sessions count toward it.

A typical request includes:

1. The psychiatric evaluation confirming the diagnosis and severity.
2. Medication trial records with drug, dose, duration, and response.
3. A baseline rating scale score, such as the PHQ-9.
4. A candidacy assessment that rules out contraindications.
5. The treatment plan, with device, schedule, and planned session count.

Track sessions used against the authorization as the course runs. Request an extension before the cap, with updated progress notes and rating scores.

What Medicare pays for CPT code 90869

Medicare pays 90869 from relative value units in the annual Physician Fee Schedule. Rates change each January and vary by locality. Use the CMS Physician Fee Schedule lookup to find the current rate for your area. Commercial rates follow each payer contract.

90869 never shares a session with 90868

National Correct Coding Initiative (NCCI) edits govern how the TMS codes combine. Check the current edit tables before you set billing rules for a new program.

• 90869 with 90868: never on the same session. 90869 already includes delivery and management, so it replaces 90868 that day.
• 90869 with 90867: never on the same session. 90867 already includes the initial threshold determination.
• 90869 with an E/M visit: a same-day E/M needs a separately identifiable service, documented and billed with modifier 25.
• Add-on codes: there are no CPT add-on codes for 90869.

Common mistakes that get 90869 claims denied

Most 90869 denials come from using the code on the wrong day or without proof. Good denial management ties each denial reason to the fix before resubmission.

Before you submit a 90869 claim

Run through this list for every session coded as 90869.

• The note records a new motor threshold value for this session.
• The note states why the threshold was re-determined.
• 90868 is not on the claim for the same session.
• The session falls within the authorized count and dates.
• The ICD-10-CM code is on the payer’s covered list and matches documented severity.
• The place of service matches where the session took place.

Deep TMS and theta burst use the same code family

Deep TMS and theta burst stimulation bill under 90867, 90868, and 90869, like standard rTMS. No separate CPT codes exist for them. Coverage differs by device and cleared indication, so check both before billing.

• Standard rTMS: NeuroStar is FDA cleared for MDD. MagVenture is cleared for MDD and as an adjunct treatment for OCD in adults.
• Deep TMS (BrainsWay H-coil): FDA cleared for MDD and OCD. Some payers ask for device-specific documentation.
• Theta burst (iTBS): cleared for MDD on some systems. Some payers treat it more cautiously than standard rTMS.

Whatever the device, the 90869 rule holds. Bill it only on the session where the threshold was re-determined.

How Pabau keeps a TMS course and its claims in step

A TMS course means dozens of claims against one authorization. Pabau, the practice management and billing platform we build, stores each prior authorization as a case. It tracks the authorized sessions used, so the team sees the cap coming before it arrives.

Our claims management software submits electronic CMS-1500 claims to US payers through Claim.MD and posts ERA remittances back. Claims that need attention are flagged as Needs action, so the team can fix them quickly.

Keep every TMS claim tied to its authorization

Pabau tracks authorized TMS sessions used against each prior authorization and submits CMS-1500 claims through Claim.MD. Claims that need a fix are flagged as Needs action.

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Conclusion

Treat 90869 as an exception code. Default every session after the first to 90868. Switch to 90869 only when the note shows a re-determined threshold and the reason for it.

Errors in either direction look the same to an auditor, because the claim and the record disagree. Build the threshold value and reason into your session template, and both errors become hard to make.

Book a demo to see how Pabau tracks authorized TMS sessions and claims across a full course.

Continue your research

Billing the first session of the course? CPT code 90867 covers the initial TMS session, with cortical mapping and the first threshold determination.

Need to understand how clearinghouse submission works for psychiatric claims? 837 file submission guide explains how electronic claims reach payers and where errors surface in the transmission.

Want to verify authorization requirements before billing a new TMS payer? Insurance eligibility verification covers how to confirm both eligibility and authorization status before the first session.

Assessing a patient for TMS candidacy? CPT code 90791 covers the psychiatric diagnostic evaluation that usually comes before a course is ordered.

Building your TMS authorization request? Medical prior authorization form gives you a ready-made template for the diagnosis, history, and treatment plan payers ask for.

Frequently asked questions