Billing Code Guide for Ketamine – MyKetamineCare.com

Disclaimer: Here are some 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 MyKetamineCare™ do not take any liability for your billing practices.

Last updated: Jan 7, 2022

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 Prodecure Coding System (HCPCS) are also available in the MyKetamineCare™platform.

General principles

We recommend not coding for too many service codes on each superbill. We recommend coding only for the primary services provided and lumping all other ancillary costs into these main service codes.

Some clinics have been adding individual CPT® codes for every service possible, even if the expected reimbursement of each of these codes are small. For example, it is easy to include 5-10 or even more CPT codes for a single treatment, including codes for E&M, EKG, medication J codes, needle sticks, etc. Though many of these codes may only receive a few dollars of reimbursement, clinics may include these because there is no perceived downside as long as the codes are legitimate.
However, this does not work well for out-of-network claims submissions. If you are in network, including CPT codes for each service is fine as there is an agreement with the insurance company on reimbursement for these services. On the other hand, for out-of-network claims, there is no pre-existing contract with the insurance company and adding these additional codes slows down claims adjudication or even makes it more likely to be rejected. Adding a number of CPT codes may lead to the claim being flagged for special review.
To be as comprehensive as possible, below we have listed an array of billing codes that have been used. However, we do not recommend using most of these codes for the aforementioned reasons. We advise sticking to the core codes for IV/IM/psychotherapy/E&M etc. and lumping in costs for everything else into these codes.
Example of a $500 infusion for an established patient:

Less preferable: 96365 – $250, 99213 with 25 modifier (if infusion and E&M happens on the same day) – $150, J3490 – $20, J3475 – $20, 96127 – $10, 93041 – $15, 36000 – $15, A4222 – $10, A4215 – $10
Better: 96365 – $325, 99213 with 25 modifier – $175

Insurance companies generally give very little reimbursement (sometimes as low as a dollar or two) for the ketamine drug itself (using the J code J3490). Therefore given the above principles, it can be useful to remove the J code completely from the superbill especially as this may raise flags during claims adjudication. If you want to include the J code, you MUST include the 11 digit NDC code, dose, and unit of measure (more info below in Medications section)
A blank superbill template is attached here. Please make sure to include a patient’s diagnosis codes:

Lists of possible codes

IV

96365, 96366, 96367, 96368 – these are the primary codes for infusions and should be the bulk of the charges.

96365: 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.
96366: 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
96367: IV infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug; up to 1 hour
96368: IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion
See here for more information on infusion and injection coding.

96375: 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
96374: Therapeutic, prophylactic, or diagnostic injection; initial push or infusion less than 16 min
96376: Therapeutic, prophylactic or diagnostic injection; each additional sequential IV push of the same drug provided in a facility at intervals >30 min
36000: intro, needle/catheter into a vein
A4222: infusion supplies with pump
A4215: Needle, sterile, any size, each
QS modifier: monitored anesthesia care

IM

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

Office visit, E/M, prolonged services

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.

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

These are common and high yield codes to use.

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

These are common and high yield codes to use.

99354: observation code for first hour; direct provider supervision (often used for Spravato or IM ketamine)
99355: observation code for subsequent 30 min (often used for Spravato or IM ketamine)
99358: for the first hour of non-face-to-face services and may be billed before or after direct patient care
99359: same as 99358 but for 75-104 minutes
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)
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
Modifier 25
See here for Evaluation and Management Guidelines from the AMA

KAP

Generally KAP providers can bill for their usual psychotherapy/psychiatry codes, with additional codes for the delivery of ketamine and any patient monitoring that was conducted.

90832: Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes)
90833: add-on code for individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes), when performed with an evaluation and management service. Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837: Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more)
90834: Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes)
90836: Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service.
90838: Use add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more), when performed with an evaluation and management service.
90839: psychotherapy for crisis; 60 minutes (time range 30-74 minutes)

90840 – add-on code or each additional 30 minutes beyond the first 74 minutes.

90853: Group psychotherapy (other than multiple-family group)
90791: psychiatric diagnostic evaluations without medical services
90792: psychiatric diagnostic evaluation with medical services
90832: 30 min psychotherapy (16-37 min). Could be psychiatrist, LCSW, psychologist

90833: if coupled with E/M

90834: 45 min psychotherapy (38-52 min). Could be psychiatrist, LCSW, psychologist

90836: if coupled with E/M

90837: 60 min psychotherapy (53 min and more). Could be psychiatrist, LCSW, psychologist

90838: if coupled with E/M

90785: Interactive complexity. Add-on code for interactive complexity and may be added on to the diagnostic psychiatric evaluation (90791, 90792), to psychotherapy services (90833—90838), and to group psychotherapy (90853).
H0033: oral medication administration, direct observation
M0064: Brief visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders
And many more codes for psychotherapy

Medication

As noted above, we do not recommend adding these codes. If you do add these codes, please adhere to the rules around NDC codes, dose, and unit of measure

J3490 – ketamine J code:

J3490 can be submitted only when a specific code for the drug is not available or does not exist.
Claim form must include the below indicated information in the remarks field/reserved for local use field of the claim form or on a separate attachment: Name and Strength of Drug Administered, Amount Given, National Drug Code (NDC) Number.

If the name, strength and dosage administered of the drug are not all listed, the claim may be denied for lack of information necessary to process the claim.

Billing NDC codes are 11 digits. The NDC must follow the 5digit4digit2digit format (11-digit billing format, with no spaces, hyphens or special characters). If the NDC on the package label is less than 11 digits, a leading zero must be added to the appropriate segment to create a 5-4-2 configuration.

The NDC is usually found on the drug label or medication’s outer packaging. If the medication comes in a box with multiple vials, using the NDC on the box (outer packaging) is recommended. The number on the packaging may be less than 11 digits. An asterisk may appear as a placeholder for any leading zeros. The container label also displays information for the unit of measure for that drug.
Some packages will display fewer than 11 digits, but leading zeroes can be assumed and should be used when billing. For example: XXXX-XXXX-XX = 0XXXX-XXXX-XX, XXXXX-XXX-XX = XXXXX-0XXX-XX, XXXXX-XXXX-X = XXXXX-XXXX-0X

Make sure to include the NDC qualifier, unit of measure, and quantity as well.
See example explanation here.

J codes for other medications that may be provided. Some examples:

J3475: injected magnesium sulfate
J2405: Ondansetron HCL Injection
J2765: Metoclopramide HCL injection
J2250: Injection midazolam hydroch
J7030, J7040, J7050: infusion normal saline
J1200: diphenhydramine

Patient monitoring

93041: ECG, 1-3 leads, tracing without interpretation or report
94760, 94761: pulse oximetry
2000F: blood pressure measured
A4670: automatic blood pressure monitor
E0445: oximeter device for measuring blood oxygen levels non-invasively
2010F: vital signs (temp, pulse, RR, BP) documented and reviewed

Measurement-based care

You can actually use billing codes for your practice of measurement-based care using the MyKetamineCare™ 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.

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

G0444 (HCPCS code): depression screening for Part B patients instead of 96127
96160: Instrument-based assessment of the patient’s risk for certain health conditions, behaviors that may negatively impact health, and pros and cons for initiating behavior change