Draft Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (DA57693)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act (SSA) 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), and (E). Investigational or Experimental.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD DL37088 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy as well as include sufficient detail to determine services rendered.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.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 GuidelinesThe 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 treatment sessions over a 4-week period followed by five visits for tapering for those in remission. For those who show at least 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.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 was 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.Maintenance therapy is considered experimental/investigational and therefore non-covered as not medically reasonable and necessary.