Article - Billing and Coding: Transcranial Magnetic Stimulation (A57528)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1) (D) prohibits the payment for clinical care items and services for research and experimentation which are not reasonable and necessary.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Transcranial Magnetic Stimulation.Coding Information: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.Documentation Requirements:All documentation must be maintained in the patients medical record and available to the contractor upon request.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 submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record documentation must support the medical necessity of the services as directed in the related LCD.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:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.The treatment must be provided by use of a device approved or cleared 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.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.Maintenance therapy is not covered.The TMS treatment planning service (CPT code 90867) may be reported once per treatment episode.