Ketamine Billing Code Guide

This guide is designed to offer a comprehensive understanding of ketamine billing codes for innovative psychiatry practices.

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We'll cover:

• The role of billing codes, and the nuances around ketamine

• Types of billing codes relevant to ketamine practices

• Steps you need to take before documenting billing codes

• Specific billing codes for IV ketamine/IM ketamine, KAP, and adjacent services

• Examples of how to structure your billing codes

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What are the Role of Ketamine Billing Codes and Initial Procedures?

CPT codes are integral to healthcare practices. They streamline the billing and claims process, aiding in compliance and potentially facilitating reimbursement. Although insurance may not always cover specific treatments like ketamine and Spravato, the usage of these codes allows the generation of superbills for patients. These documents can subsequently aid patients in seeking potential reimbursement.

It is essential to note that services usually gain coverage if the correct preliminary procedures are followed. However, authorizations can be denied if the provider is out-of-network (OON) and there's no in-network (INN) provider within a 30-75 mile radius. In such cases, patients are often responsible for treatment costs.

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What are CPT codes, J Codes, HCPS Codes, Modifiers, and ICD-10 Codes?

Medical billing is its own language. Besides CPT codes, you have J-codes, HCPCS codes, modifiers, ICD-10/DX codes.

Ketamine is not typically covered by insurance because the FDA still recognizes it for off-label use. Some Payers let you use NDC codes that are NOC (not otherwise classified), but they are now asking providers to be more specific. If you bill out for NDC codes that list Ketamine as the medication they will often lead to denials. However, you can still try using code groupings throughout this guide.

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This table summarizes the key differences between code types and when to use them:

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Preliminary procedures you need to take before documenting any billing code(s)

• Verify benefits correctly before the first appointment

• Group CPT codes based on fee schedule reimbursements

• Ensure that you have the correct prior authorization in place for all possible variations of CPT codes that could be used.

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Let’s dive into these foundational steps in this section, before outlining specific billing codes:

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Understanding Workflow and Prior Authorization Process

This includes verifying insurance benefits prior to the first appointment, grouping CPT codes based on fee schedule reimbursements, and having the correct prior authorization in place for all variations of CPT codes that could potentially be used. It's also important to note that authorizations may be denied if the provider is out of network and an in-network provider is available within a certain distance. Note that IV ketamine prior authorizations are off-label, and you typically need to go through an oncologist. This approach may take longer, but you will encounter less pushback from payers than if you use generic J-codes.

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Where Can You Find Prior Authorizations?

There are resources available for finding prior authorizations for ketamine and Spravato treatments. These include payer-specific websites, third-party services, and software platforms that offer assistance with billing and claims management. It's important to do research and choose a reliable source for obtaining prior authorizations to ensure compliance and avoid potential clawbacks from insurance companies.

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Playing it Safe with Ketamine Billing Codes

To avoid potential issues with insurance companies, it's important to play it safe with billing codes for ketamine practices. This includes coding only for the primary services provided and lumping all other ancillary costs into the main service codes. Adding more procedure codes should only be done with the correct use of modifiers and CPT codes, and the codes listed on the prior authorization should match those listed on the fee schedule. It's also recommended to remove J codes for ketamine from the superbill, as insurance companies generally give very little reimbursement for the drug itself.

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Disclaimer: In this guide, you’ll find general suggestions for ketamine clinics. We cannot guarantee that these suggestions will work for your clinic and please make sure to follow any relevant rules or guidelines. We are not billing experts and suggest that you consult with one if needed. By reading this article, you acknowledge that this post is not legal advice and the authors and Osmind do not take any liability for your billing practices.

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Geographic considerations and cost savings

Typically, services will be covered if you follow proper procedures from the start. However, authorizations will be denied if you are out of network and an in-network provider is within 30-75 miles. In these cases, costs for treatment would likely become the patient's responsibility.

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Now let’s cover the latest ketamine billing codes that every ketamine and interventional psychiatry practice needs to know:

• What are the different types of billing codes?

• Which codes should you use/focus on for easy and efficient billing, superbill, and claims submission? Codes for:

• Ketamine infusion*

• IM injections*

• KAP (Ketamine-assisted psychotherapy)*

• Psychotherapy

• Office visits, Evaluation and Management (E/M), prolonged services

• Patient monitoring

• Medications

• Measurement-based care

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Ketamine Infusion/IV Billing codes

Note: There is no orthodox way to bill for this service. For liability reasons, we can’t formally recommend these codes, but some ketamine providers have found some success.

Read also: IV Ketamine Documentation Guide + Free Template
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96365: primary code for infusions, up to 1 hour, highest yield.

• Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration) up to 1 hour. This is the code that virtually all IV ketamine providers use and is highest yield.

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96366: additional hour of sequential infusion.

• add-on code for 96365 and 96367: Report for additional hour of sequential infusion. Report 96366 with 96365 to identify each subsequent infusion of the same drug.

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96367: IV infusion of new drug, up to 1 hour.

• IV infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug; up to 1 hour.

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6368: concurrent IV infusion.

• IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion.
• See here for more information on infusion and injection coding.

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96375: additional sequential IV push of a new drug.

• Therapeutic, prophylactic, or diagnostic injection; each additional sequential IV push of a new drug. add-on code for 96365 and a few others. Report 96375 to identify IV push of new drug after an initial service is administered.

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96374: initial push or infusion less than 16 minutes.

• Therapeutic, prophylactic, or diagnostic injection; initial push or infusion less than 16 min.

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96376: additional sequential IV push of the same drug at intervals >30 minutes.

• Therapeutic, prophylactic or diagnostic injection; each additional sequential IV push of the same drug provided in a facility at intervals >30 min

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36000: intro, needle/catheter into a vein.

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A4222: infusion supplies with pump.

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A4215: Needle, sterile, any size, each.

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QS modifier: monitored anesthesia care.

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Ketamine IM Injection CPT codes

Note: There is no orthodox way to bill for this service and it’s still not an FDA approved.

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96372: Therapeutic, prophylactic, or diagnostic injection, SC or IM.

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Table View:

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Office visit, Evaluation and Management (E/M), prolonged services CPT Codes

There are unfortunately lots of rules around billing using E/M codes. To reduce the probability of rejected claims, please make sure to follow all of them. Here is some guidance from CMS.

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99201-99205: New patient E/M

• This is for initial assessment on a visit during which a treatment was not provided. E/M codes should typically be billed on separate days as infusions

• Make sure to include the 25 modifier if billing on the same date as the infusion.

• Modifier 25: if the service was provided on the same date, this modifier should be included. It indicates a significant, separately identifiable preventive or other E/M service that was provided on the same date

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99211-99215: established patient E/M

• 99213 and 99214 seem to be most popular, with 99215 and 99212 also used with regularity. E/M codes should typically be billed on separate days as infusions

• Make sure to include the 25 modifier if billing on the same date as the infusion.

• Modifier 25: if the service was provided on the same date, this modifier should be included. It indicates a significant, separately identifiable preventive or other E/M service that was provided on the same date

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New AMA guidelines came out. They created a placeholder for observation codes, but they are only allowing you to use codes 99415-99417 for inpatient visits.

Codes 99354 and 99355 can now be replaced with 99415, 99416, or 99417.

You can bill either the 99415 and 99416 together (for each additional 30 minutes), or the 99417 alone. These groupings are exclusive, meaning it's never all three and they are never mixed. So, the options are either 99417 with four units or 99415 with 99416.

• 99417 x 4 units is the most common.

• 99415: Prolonged clinical staff service (the service beyond the typical service time) during an E/M service in the office or outpatient setting, direct patient contact with physician supervision: first hour (list separately in addition to code for outpatient E/M service)

• When 99415 is used it's usually paired with 99416.

• 99417 would be billed for the additional time or 99415 + possibly 99416 but never all 3 together. Its an either-or scenario on those codes.

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90885: when a provider is asked to do a review of records for psychiatric evaluation without direct patient contact. This may be accomplished at the request of an agency or peer review organization. It may also be employed as part of an overall evaluation of a patient’s psychiatric illness or suspected psychiatric illness, to aid in the diagnosis and/or treatment plan

90887: used when the treatment of the patient may require explanations to the family, employers or other involved persons for their support in the therapy process. This may include reporting of examinations, procedures, and other accumulated data.

90889: Preparation of report of patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers.

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Table view:

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Ketamine-Assisted Psychotherapy(KAP)/General Therapy CPT Codes

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Non-Evaluation and Management (E&M) Codes:

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90832: Individual psychotherapy, 30 minutes with the patient and/or family member (time range 16-37 minutes)

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90834: Individual psychotherapy, 45 minutes with the patient and/or family member (time range 38-52 minutes)

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90837: Individual psychotherapy, 60 minutes with the patient and/or family member (time range 53 minutes or more)

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90839: Psychotherapy for crisis, first 60 minutes (time range 30-74 minutes)

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90840: Add-on code to 90839 for each additional 30 minutes beyond the first 74 minutes

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90853: Group psychotherapy (other than multiple-family group)

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90846: Family Psychotherapy (without the patient present)

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90847: Family Psychotherapy (with the patient present)

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90791: Psychiatric diagnostic evaluations without medical services

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90792: Psychiatric diagnostic evaluation with medical services

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96127 with a 59 modifier: Used for conducting assessments like BDI, PHQ9 (max of 4 units per quarter)

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90785 with a 59 modifier: Interactive complexity

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99202-99205: Office visit codes for buy and bill

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99212-99215: Office or other outpatient visit codes

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99416-99417: Prolonged preventive service(s) codes

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E&M Billing Codes:

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90833: Add-on code for 30-minute psychotherapy session, if coupled with E/M

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90836: Add-on code for 45-minute psychotherapy session, if coupled with E/M

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90838: Add-on code for 60-minute psychotherapy session, if coupled with E/M

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Ketamine Assisted Psychotherapy (KAP) Billing Codes

All the Non-E&M and E&M therapy codes listed above are also applicable for KAP, with additional codes for the delivery of ketamine and any patient monitoring conducted.

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Note: Prolonged codes (G2112, 99417) cannot be used with therapy add-on codes.

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If a service like Spravato or ketamine is billed on the same day and a non-E&M therapy is performed afterwards, an XP modifier must be used if the provider rendering the services differs. If the same provider is conducting incident-to-billing or providing both med management services and incident-to-billing services on the same day, add-on codes should suffice.

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99212: Established patient office or other outpatient visit, 10-19 minutes.

This code is for an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.

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99213: Established patient office or other outpatient visit, 20-29 minutes.

This is for an office visit for an established patient with a stable chronic illness or acute uncomplicated injury. It requires a medically appropriate history and/or examination and low level of medical decision making.

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99214: Established patient office or other outpatient visit, 30-39 minutes.

This is for an office visit for an established patient with a progressing illness or acute injury that requires medical management or potential surgical treatment. It requires a medically appropriate history and/or examination and moderate level of medical decision making.

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99125: used to report each additional 40-54 minutes of prolonged clinical staff service beyond the first hour.

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99416: used to report each additional 30 minutes of prolonged clinical staff service beyond the first hour.

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99417: prolonged office or other evaluation and management services that requires at least 15 minutes or more of total time either with OR without direct patient contact on the date of the primary E&M service (either CPT® codes 99205 or 99215).

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Table view:

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Measurement-based care Billing Codes

You can actually use billing codes for your practice of measurement-based care using the Osmind platform! These codes are generally covered by major insurance companies, although payers may specific certain diagnosis codes that should be present or certain questionnaires to use for each code.

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96127: behavioral health assessment - this is the primary code

• “Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument"

• CPT Code 96127 may be billed four times for each patient per visit**,** utilizing four different instruments or assessments

• Screening and assessment has to be completed under an MD supervision, and a MD needs to file the report.

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The Bottom Line with Reimbursement for Ketamine Treatments

Insurance companies typically reimburse very little (sometimes just a dollar or two) for the ketamine drug itself (identified by the J code J3490).  Therefore, you may find it useful to remove the J code completely from the superbill—especially since this could raise flags during claims processing.  If you want to include the J code, you MUST provide the 11-digit NDC code, dosage, and unit of measure (more details below in the Medications section).

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Let’s look at an example of a $500 infusion for an established patient:

• 96365 - $325,

• 99213 with 25 modifier - $175

• 99205 with modifier 25 - $35090833 with modifier 25 -  $200

Aside from the grouping listing, the information will vary significantly by practice.  Many practices may not use, for example, EKG monitoring or the additional J code for other drugs.  Also, supply-wise, the A code is bundled into the IV infusion service itself.  In general, each CPT code includes the cost of the service and supplies, so just because an HCPCS supply code exists does not mean it will be reimbursed; It typically won’t be.  Some carriers may pay for it, but that’s definitely not the norm.

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Ketamine is typically not covered by insurance because the FDA still considers it for off-label use. Some insurance companies will accept generic codes labeled as NOC (not otherwise classified), but now they want more details. Billing for generic codes that specifically say Ketamine often leads to denied claims.

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The safest choice is to get an oncologist to prescribe ketamine for off-label use. Although limited research exists since few providers want to do the required steps, we have seen some success. While few want to try this, it is an option since it eliminates the risk of insurance companies taking back money, which can happen when using generic J codes. However, this may take longer. We recommend caution but below are some codes to try.

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Ketamine Billing Coding Principles

We recommend only coding for the primary services provided and lumping all other ancillary costs into the main service codes. You can opt to add individual CPT codes for every service. As long as you are doing your eligibility checks in the beginning, and even if you add on these codes, if you are INN they will process as INN.

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Some of this will vary by carrier as to which will commonly request additional information before processing a claim.

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You should also know you can have claims and superbills populate with only the primary diagnosis, which will not affect your charting and all other diagnoses can still be included in your chart note.

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When to add more ketamine procedure codes

Adding more procedure codes will be accepted at an out-of-network level, depending largely on prior authorization and the correct use of modifiers/CPT codes. Ensure the CPT codes you list are on your fee schedule so you can be reimbursed. If not, make sure they are all listed on the prior authorization. The Claims typically process and pay out much faster if an auth is required. There's no control over whether the carrier will or will not require an auth and its solely based on the type of plan a patient has.

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For out-of-network claims, ensure any agreement you sign lists all CPT codes and uses the right modifiers/location code combinations.

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Conclusion:

It’s essential for private mental health practices to be well-versed in the various code sets and know how to use them correctly when billing insurance or providing a superbill. This includes being familiar with the different types of codes, when to apply each one, and the correct use of modifiers and ICD-10/DX codes.

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Inaccurate or incorrect coding can lead to denied claims or reduced reimbursement, so it’s important to have a thorough understanding of the coding requirements and stay up-to-date with changes in the coding rules and regulations.

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In addition to being knowledgeable about the codes, mental health practices should also be familiar with the billing and reimbursement process. This includes submitting claims to insurance companies, responding to insurance company requests for additional information, and dealing with denied claims.

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CPT® copyright 2023 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.

Healthcare Common Procedure Coding System (HCPCS) is also available in the Osmind platform. It may also be helpful to work with a medical billing specialist or to consult with billing and coding resources and guides to ensure that all coding and billing requirements are met.

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