Osmind 360: TMS Coding Guide

Last updated: October 8, 2026

A practical reference for coding transcranial magnetic stimulation (TMS) — from the initial evaluation through the full treatment course — so your team can bill accurately and keep claims moving.

At a Glance

Code	What It Is	When to Use It	Frequency
99204 / 99205	New patient E/M	TMS candidacy evaluation for a patient new to your practice	Once
99214 / 99215	Established patient E/M	TMS candidacy evaluation for a current patient	As needed
90867	Initial TMS delivery & management, incl. cortical mapping and motor threshold determination	First treatment session of the course	Once per course
90868	Subsequent TMS delivery & management	Every routine daily treatment after the first	1 unit per session
90869	Subsequent motor threshold re-determination with delivery & management	Any session where the motor threshold is re-determined	Replaces 90868 that day

1. The Initial TMS Evaluation

Before treatment begins, a comprehensive psychiatric evaluation establishes medical necessity. This is a standard medical evaluation, so it's billed with Evaluation and Management (E/M) codes — not TMS procedure codes.

Key rule: new vs. established patient
New patient: has not received professional services from a clinician of the same specialty in your group within the past 3 years.
Established patient: a patient you already treat (for example, for medication management) who is now being evaluated for TMS remains established. A first TMS conversation does not make them a new patient.

New Patients to Your Practice

Code	Level	Example
99204	Moderate medical decision-making (MDM), or 45–59 total minutes on the date of service	A 50-minute intake: you review a history of failed SSRIs, diagnose severe major depressive disorder, and discuss the TMS protocol and its risks and benefits.
99205	High MDM, or 60–74 total minutes on the date of service	A 65-minute intake for a patient with a complex psychiatric history and multiple comorbidities, requiring extensive review of outside records and coordination with their neurologist before TMS clearance.

Established Patients Moving to TMS

Code	Level	Example
99214	Moderate MDM, or 30–39 total minutes	A 35-minute visit with a patient you've treated for a year: you determine the current medication regimen is failing, document treatment resistance, and shift the treatment plan to TMS.
99215	High MDM, or 40–54 total minutes	A 45-minute deep dive into severe, treatment-resistant depression: you outline a new treatment plan that includes TMS and gather the clinical documentation needed for prior authorization.

Tip:
Total time includes all clinician time on the date of service — face-to-face and non-face-to-face (record review, documentation, care coordination). Document the total time or the MDM elements that support the level you bill.

2. The TMS Treatment Course

Once the patient is authorized, billing shifts from E/M codes to TMS procedure codes. A standard course is one initial mapping session followed by roughly 30–36 daily treatments over about six weeks.

Code	What's Included	Billing Rule	Who Performs It
90867	Initial delivery & mapping. Cortical mapping, motor threshold determination, device parameter setup, and the first therapeutic treatment.	Typically billed once per treatment course (episode of care).	The supervising physician is generally present and directly involved.
90868	Subsequent delivery. Routine daily stimulation and standard patient management. Your highest-volume TMS code.	1 unit for each session after the first — often 30–36 over the course.	A trained TMS technician under the level of physician supervision the payer requires.
90869	Motor threshold re-determination. Used when the threshold must be recalculated mid-course — e.g., after a medication change, lack of progress, or a lapse in treatment days. Includes that day's treatment.	Replaces 90868 on that day. Never bill 90868 and 90869 on the same date.	Physician-directed re-determination.

Example: A 36-Session Course

Day 1

90867 ×1

Days 2–15

90868 ×1 per day

Day 16

90869 ×1

Days 17–36

90868 ×1 per day

Day 1: The physician maps the patient, determines the motor threshold, and delivers the first treatment → 90867 (1 unit).
Days 2–15: Standard daily treatments → 90868 (1 unit per day).
Day 16: The patient reports a change in concurrent medications, so the physician re-determines the motor threshold before treating → 90869 (1 unit).
Days 17–36: Standard daily treatments resume → 90868 (1 unit per day).

3. Payer Rules & Prior Authorization

TMS is a high-cost treatment, and payers apply strict reimbursement criteria. These are the areas most likely to cause denials.

Diagnosis Specificity

Most payers, including Medicare, cover TMS only for treatment-resistant major depressive disorder. The most widely accepted ICD-10-CM codes are:

ICD-10	Description
F32.2	Major depressive disorder, single episode, severe without psychotic features
F33.2	Major depressive disorder, recurrent, severe without psychotic features

Billing TMS for other diagnoses without a specific prior authorization will very likely be denied.

OCD coverage: Some commercial payers — including Cigna, BCBS of Michigan, BCBS of Texas, and Optum — have policies that may cover TMS for obsessive-compulsive disorder. Criteria (such as device type and prior treatment requirements) vary by plan, so confirm the current policy and obtain authorization before starting.

Prior Authorization

Unlike a standard office visit, TMS almost always requires prior authorization before the first mapping session (90867). Expect to submit documentation of treatment resistance, which typically includes:

Failed trials of multiple antidepressants from different classes (with doses, durations, and outcomes)
An adequate trial of evidence-based psychotherapy
Current symptom severity, ideally with a validated scale (e.g., PHQ-9)

Same-Day Services

Psychotherapy: If a physician or therapist conducts a full, formal psychotherapy session before or after the TMS session, a psychotherapy code (such as 90834) may be billable on the same day as 90868. Documentation must clearly show the therapy was distinct from routine TMS management, and Modifier 59 is often required. Confirm with the payer to avoid bundling denials.

Before You Submit — Checklist

Correct new vs. established status for the evaluation visit
Prior authorization approved, with the authorized number of sessions and date range on file
Covered diagnosis (e.g., F32.2 or F33.2) on every TMS claim
90867 billed only once for the course
No 90868 and 90869 on the same date of service
Session count tracked against the authorization — request an extension before the limit is reached
Supervision requirements met per the payer's policy

This guide is for general educational purposes and reflects common industry coding practice. It is not legal or billing advice. CPT® is a registered trademark of the American Medical Association. Coverage policies, supervision rules, and modifier requirements vary by payer and change over time — always confirm current requirements with each payer before billing. Questions? Reach out to your Osmind team.