Spravato TMS billing Texas: It’s an apparent paradox How can you bill for Spravato (esketamine) and TMS (Transcranial Magnetic Stimulation) at once? It makes you want to pull your hair out — especially with Texas’ very strict rules.
But with a perfect regimen, your clinic can remain REMS compliant and prevent billing errors as you continue to get paid on time.This is how you can do it, step by step.
What REMS Is, and Why We Should Care
Spravato is a unique depression treatment that is only approved for use through a program known as REMS — or Risk Evaluation and Mitigation Strategy. The REMS program provides patient protection by ensuring that Spravato is administered in a safe and monitored setting.
In order to remain compliant and bill accurately, your clinic will need to take the following precautions:
1. Get REMS-Certified
Spravato can be administered only by a REMS-certified clinic.
“Certification says your team knows about the risks, such as sedation or dissociation, and how to manage them.”
2. Assign an Authorized Representative
You only require a single trained individual to be designated as your REMS Representative.
They facilitate certification, training, and communication with the Spravato REMS program.
3. Enroll Every Patient
Patients will need to enroll in the REMS program before receiving their first dose.
This shows they know how Syodpat o is to be taken and accept the monitoring requirements.
4. Observe and Monitor
Spravato is taken under strictly controlled conditions. The patient is required to remain in the clinic for a minimum of 2 h postdose.
A pulse oximeter is an ideal solution to keep a track of their breathing and oxygen levels.
5. Report and Record
Fill out the Patient Monitoring Form at the end of every treatment session, and submit form to REMS within 7days.
Always retain a copy for your records — it’s proof of medical necessity and shields your practice from audits.
TMS Treatment Requirements in Texas
TMS treatment also is unambiguous with coverage for billing regulations.
In order to receive payment from an insurance company, providers have to indicate medical necessity and assess progress with rating tools (PHQ-9 or HAM-D).
Main TMS Billing Codes
- 90867 – Initial session and plan for treatment
- 90868 – Follow-up sessions
- Progress notes – Record changes and outcome
Many Texas Medicaid and private insurers require prior authorization and frequent updates so they can approve more sessions.
Spravato TMS billing Texas on same day
A few clinics offer both types of treatment within a single visit. It might be — but it requires careful billing and clear documentation.
1. Prove Medical Necessity
Demonstrate why both procedures are required.
For example, a patient with treatment-resistant depression might receive rapid relief from Spravato while benefiting from long-term support from TMS.
Your chart should list:
- Diagnosis and symptom history
- Failed medications
- Why treatment with both is included in the care plan
Get the Codes and Modifiers Right
| Service | Code Type | Common Codes | Modifier | Notes |
| Spravato Administration | E/M + Drug | 99212–99215 + J3490 / C9399 | 25 | For same-day visit with other procedure |
| TMS Initial Planning | CPT | 90867 | 59 | Used for distinct service |
| TMS Ongoing Session | CPT | 90868 | 59 | Use for follow-up sessions |
Tip: Never bill with Modifier 25 or 59 unless services are distinct and completely documented.
Manage Prior Authorization and Payer Rules
In Texas, different payers have different rules.
Before billing, always confirm:
- If both treatments require authorization
- Accepted CPT / HCPCS codes
- Documentation and time-tracking needs
- How to report observation time
Example:
One Austin Clinic was billing with TMS codes and using Modifier 59, as well as generating extensive progress notes. The initially denied visits were reimbursed upon resubmission.
REMS-Compliant Billing in a Few Easy Steps
| Step | Action | Compliance Focus | Billing Tip |
| 1 | Check patient REMS enrollment | Verify certification | Include REMS ID |
| 2 | Administer under observation | Follow 2-hour rule | Record times |
| 3 | Complete monitoring form | Submit in 7 days | Keep copy on file |
| 4 | Bill for each service | Use correct codes | Match documentation |
| 5 | Add modifiers | For same-day care | Note reason in chart |
Keeping this workflow in place makes your process smoother and reduces errors.
Keep Great Documentation
But strong documentation protects your practice and can assist with an audit or claim review.
Make sure your notes include:
- Individual start and end times of treatments
- Each provider’s name and role
- Patient response, toxicity
- Prior authorization details
- Confirmation of REMS reporting
Insurance companies are much less likely to delay or deny payments when records are clear.
Best Practices for Texas Psychiatry Clinics
The best Texas clinics, including The Medicators, use these best practices:
- If possible, try to schedule Spravato and TMS on separate days.
- If it’s the same day, write separate notes for each service.
- Appropriate modifier assignment and HCPCS/CPT code utilization.
- Keep REMS training current for your staff.
- Partner with reliable Psychiatry Billing Services in Texas for compliance and claims processing.
Real-World Success Example
A psychiatry clinic in Dallas had offered both treatments but was denied repeatedly.
They teamed up with The Medicators to assist them:
- Independent documentation for TMS and Spravato
- Add proper modifiers (25 and 59)
- Attach REMS compliance proof
Result: Refusals were reduced by 60%, and times for compensation built up within two billing cycles.
Why The Medicators Stand Out
The Medicators – The Medicators offers an expert psychiatry billing service in Texas exclusively for mental and behavioral health providers.
Their staff is up to speed with the complexities of Spravato REMS compliance, TMS billing, and Texas Medicaid payer rules.
They help clinics with:
- Prior authorization
- Claim submissions
- Denial management
- Compliance tracking
- Revenue cycle optimization
By leveraging expertise in psychiatry billing, clinics can not only save time and mitigate errors but also concentrate on caring for patients.
Conclusion: Simple, Easy and No Head Aches Billing
Don’t let the task of management Spravato TMS billing Texas stress you out.
Instructions for successful compliance If your clinic follows REMS requirements, uses specific modifiers and keeps detailed notes, then you can remain compliant and get paid quickly.
And you want the experts, The Medicators, to help you ensure that billing for your Spravato + TMS is simple, accurate and stress free.
