Spravato vs. Antidepressants: Which is Better?
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Learn Spravato Coding & Reimbursement Now!
Navigating the coverage and reimbursement landscape for SPRAVATO® (esketamine) nasal spray requires careful consideration to ensure compliance and optimize reimbursement. The assignment of a Healthcare Common Procedure Coding System (HCPCS) code and a payment rate does not guarantee coverage by Medicare, Medicaid, or private payers. Each payer determines whether a drug, device, procedure, or service meets its specific reimbursement criteria.
Healthcare providers should verify each patient’s insurance coverage and payer policies to facilitate proper reimbursement for SPRAVATO® treatment.
Disclaimer: This guide provides general coding information and does not constitute legal or billing advice. Reimbursement for codes depends on credentialing, contracting, and accurate usage for any given entity.
Key Considerations for Reimbursement
Payer Policies: Coverage and coding requirements for SPRAVATO® vary among payers. Some insurance plans may utilize Behavioral Health Organizations (BHOs) to manage mental health benefits. Contacting the BHO can help clarify reimbursement and coding options.
Prior Authorization (PA): Many payers require prior authorization before approving SPRAVATO® treatment. Utilizing resources such as the SPRAVATO® Prior Authorization Toolkit can streamline the process.
Coding and Billing: Providers must select appropriate codes based on the patient’s condition, services rendered, and specific payer requirements. Contacting local payers for their payment policies ensures proper documentation and reimbursement.
Procurement Methods: The method of acquiring SPRAVATO® impacts billing and reimbursement. In the “buy and bill” model, the provider purchases the drug, administers it, and submits a claim for reimbursement. Alternatively, SPRAVATO® can be obtained through REMS-certified specialty pharmacies. Each method has different payer requirements.
Billing Codes for Spravato Therapy
Prior Authorization and Coverage Considerations
- Verify Insurance Benefits – Confirm each patient’s coverage before the first appointment.
- Obtain Prior Authorization – Many payers require PA for SPRAVATO®. Ensure all documentation is submitted accurately.
- Ensure Proper Coding – Use the correct HCPCS, CPT®, and ICD-10 codes based on the services provided.
- Understand Payer Policies – Contact payers directly to clarify reimbursement requirements and policies.
- Confirm Procurement Method – Determine whether the buy-and-bill model or specialty pharmacy acquisition is the best fit for your practice.
Reminder: Healthcare providers should consult with each patient’s insurance provider since coverage and reimbursement levels vary.
Conclusion
Accurate billing practices ensure compliance and optimize reimbursement. Mental health providers must:
- Use the correct codes and modifiers.
- Obtain necessary prior authorizations.
- Stay updated on insurance and billing regulations.
Errors in billing can lead to denied claims and lost revenue. Schedule a service overview with Focal Point to discuss how our billing and virtual assisting services can add value to your practice!
