90867

Therapeutic repetitive Transcranial Magnetic Stimulation (rTMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management

Repetitive Transcranial Magnetic Stimulation (rTMS) is a sophisticated non-invasive neurostimulation procedure used to modulate neuronal activity in specific regions of the brain. CPT code 90867 represents the comprehensive initial session of a treatment course, which is fundamentally different from subsequent daily treatment sessions. This initial encounter involves the intricate process of cortical mapping and motor threshold (MT) determination. The physician or qualified healthcare professional utilizes a magnetic coil placed against the patient's scalp to deliver high-intensity magnetic pulses. These pulses pass through the skull and induce electrical currents in the underlying cortical tissue. The primary objective during the 90867 session is to locate the primary motor cortex and identify the 'motor hotspot' that controls the contralateral hand muscles, typically the abductor pollicis brevis. The motor threshold is then established as the minimum stimulation intensity required to elicit a visible muscle twitch or an electromyographic response in at least 50 percent of trials. This threshold serves as the physiological basis for dosing the therapeutic pulses, which are usually delivered at 110 percent to 120 percent of the MT. Once the MT is defined, the clinician maps the distance to the target treatment area, most commonly the dorsolateral prefrontal cortex (DLPFC), which is involved in mood regulation. The procedure includes the actual delivery of the first treatment series and constant clinical management of the patient's physiological and psychological response during the session. This session is critical for ensuring both the safety and the efficacy of the entire therapeutic course, as it establishes the precise spatial coordinates and intensity parameters for all following sessions.

Clinical Indications

  • Treatment-resistant major depressive disorder (MDD) in adults
  • Major depressive disorder with comorbid generalized anxiety disorder (anxious depression)
  • Obsessive-Compulsive Disorder (OCD) when using FDA-cleared protocols
  • Failure to achieve satisfactory improvement from prior antidepressant pharmacological trials
  • Patient preference for non-invasive neuromodulation over electroconvulsive therapy (ECT)

Procedure Steps

  1. Position the patient in a specialized treatment chair and ensure comfort.
  2. Perform scalp measurements using the 10-20 EEG system or a cap-based coordinate system to identify landmarks.
  3. Place the electromagnetic coil over the presumed primary motor cortex (M1).
  4. Deliver test pulses to identify the optimal location ('hotspot') for eliciting a motor response in the hand.
  5. Determine the resting motor threshold (MT) by titrating the magnetic intensity until the minimum effective dose is found.
  6. Calculate the therapeutic target site, typically 5-6 cm anterior to the motor hotspot along the scalp's curvature to reach the DLPFC.
  7. Secure the coil in the therapeutic position using a mechanical arm or tracking system.
  8. Administer the first full series of repetitive pulses based on the prescribed protocol (e.g., 10 Hz or intermittent Theta Burst).
  9. Monitor the patient throughout the session for adverse events like headache, scalp pain, or syncope.
  10. Document all parameters including intensity, frequency, total pulses, and anatomical coordinates for subsequent sessions.

Coding Guidelines

  • Report 90867 only once per course of treatment to represent the initial planning and treatment delivery.
  • Do not report 90867 in conjunction with 90868 or 90869 on the same date of service.
  • The service must be performed by a physician or other qualified healthcare professional; if a technician performs the delivery alone under supervision, see 90868.
  • 90867 includes the work of the first treatment delivery; do not bill an additional 90868 for the first day.
  • Evaluation and Management (E/M) services may be reported on the same day only if a separate and identifiable service is performed and documented, appended with modifier 25.
  • Psychiatric diagnostic evaluation (90791-90792) is typically performed on a preceding day and is not included in 90867.

Associated ICD-10 Codes