Billing and Coding: Transcranial Magnetic Stimulation (TMS)

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L36469-Transcranial Magnetic Stimulation
(TMS).

**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.

**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.

Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.

The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

1\. All documentation must be maintained in the patient's medical record and
available to the contractor upon request.

2\. Every page of the record must be legible and include appropriate patient
identification information (e.g., complete name, dates of service(s)). The
documentation must include the legible signature of the physician or non-
physician practitioner responsible for and providing the care to the patient.

3\. The medical record documentation must support the medical necessity of the
services as directed in this policy.

4\. The attending physician must monitor and document the patient's clinical
progress during treatment. The attending physician must use evidence-based
validated depression monitoring scales such as the Geriatric Depression Scale
(GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck
Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the
Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of
Depressive Symptomatology (QIDS) or the Inventory for Depressive
Symptomatology Systems Review (IDS-SR) to monitor treatment response and the
achievement of remission of symptoms.

**Utilization Guidelines**

The treatment must be provided by use of a device approved by the FDA for the
purpose of supplying Transcranial Magnetic Stimulation.

It is expected that the services would be performed as indicated by current
medical literature and standards of practice. Services performed in excess of
established parameters may be subject to review for medical necessity.

TMS is reasonable and necessary for up to 20 visits over a 4 week period
followed by five visits for tapering for those in remission. For those who
show at least a 25% improvement by means of the standard tests for depression,
the therapy may be continued for an additional 2 weeks (an additional 10
visits) with an additional 6 visits for tapering. Further treatment of an
episode of depression beyond this, for patients who have not achieved at least
a 50% reduction in symptoms will be considered not medically reasonable and
necessary and not subject to coverage.

Retreatment may be considered for patients who met the guidelines for initial
treatment and subsequently developed relapse of depressive symptoms if the
patient responded to prior treatments as evidenced by a greater than 50%
improvement in standard rating scale measurements for depressive symptoms or
if there were a relapse after remission...(e.g., (GDS), PHQ-9, BDI, HAM-D,
MADRS, QIDS or IDS-SR score. A repeat treatment program is allowed as above.