Sunday, March 26, 2017

CPT 90867, 90869 - RTMS for resistant depression


Group 1 Paragraph: N/A

Group 1 Codes:
90867 Tcranial magn stim tx plan
90868 Tcranial magn stim tx deli
90869 Tcran magn stim redetemine

Coverage Indications, Limitations, and/or Medical Necessity


Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive treatment that uses magnetic resonance pulsed fields to induce an electric current in the brain. Repetitive TMS can either decrease or increase the excitability of the targeted structures.

In 2008 the U.S. Food and Drug Administration (FDA) granted 510(k) marketing clearance as a de novo device for NeuroStar ® TMS to be utilized as a Class II rTMS device for the treatment of major depressive disorder in patients who had not responded to one adequate trial of antidepressant medication. A September 2011 AHRQ report “Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults. Comparative Effectiveness Review” found that rTMS was beneficial relative to controls receiving a sham procedure for all three outcomes (severity of depressive symptoms, response rate, remission rate), with high strength of evidence for severity of depressive symptoms and response rate, and moderate strength of evidence for remission rate. The AHRQ report cites that relative to sham control, rTMS averaged a decrease in depressive severity measured by the Hamilton Rating Scale for Depression (HAM-D) of more than 5 points (a 3 point difference is considered clinically meaningful).

rTMS offers a well-tolerated, non-pharmacologic alternative that does not require attendant anesthesia services. When used as an antidepressant therapy, rTMS has no adverse effects on cognition, and unlike electroconvulsant therapy (ECT) does not induce amnesia or seizures. Comparative outcomes for ECT and rTMS are similar.


Left prefrontal rTMS is considered reasonable and necessary for patients diagnosed with resistant depression who also have at least one of the following:

Resistance to treatment with psychopharmacologic agents as evidenced by a lack of clinically significant response to four trials of such agents, in the current depressive episode, from at least two different agent classes. At least one of the treatment trials must have been administered at an adequate course of mono- or poly–drug therapy; or

Inability to tolerate psychopharmacologic agents as evidenced by trials of four such agents, from at least two different agent classes, with distinct side effects; or

History of good response to rTMS in a previous episode; or

If patient is currently receiving electro-convulsive therapy, rTMS may be considered reasonable and necessary as a less invasive treatment option.


rTMS is considered not reasonable and necessary when used as a treatment modality for patients with psychotic symptoms.

Use of rTMS is not indicated in patients with:

Seizure disorder, or
A vagus nerve stimulator, or
An implanted medical device or metal in close proximity to the brain.

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.



F32.2 Major depressive disorder, single episode, severe without psychotic features
F33.2 Major depressive disorder, recurrent severe without psychotic features

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