Search a database of state- and payer-specific forms and coverage documents
To view payer policy for SPRAVATO®, you can use the coverage lookup tool to search a database of state- and payer- specific forms and coverage documents for SPRAVATO®.
We are excited to introduce the SPRAVATO® Interactive Code Finder. This interactive tool is intended to help your treatment center better understand SPRAVATO® coding. Based on several factors, you will be able to utilize this to view possible coding scenarios to consider when billing and coding for SPRAVATO®.
Benefit design is a set of rules that describe coverage of healthcare services for health insurances. Typically, insurance plans manage drug coverage under the medical or pharmacy benefit, or both.
Buy and Bill is a procurement method that is typically covered under a patient’s medical benefit and is used for providers to acquire specialty and/or office-administered drugs. Providers may purchase the medication and keep the inventory on site until a patient is prescribed therapy.
Assignment of Benefits is a pathway that allows a practice to acquire drugs through a pharmacy under a patient’s medical benefit.
Specialty pharmacy is an accredited pharmacy that provides medications for complex medical conditions, such as cancer, rheumatoid arthritis, and multiple sclerosis.
S codes are Level II HCPCS codes that are issued to meet the needs of non-Federal (ie, commercial) payers to describe products and services for which there are no nationally accepted codes. The Medicare program does not use, and does not accept claims for, S codes.
J codes are types of HCPCS codes used for billing specific non-oral medications, such as chemotherapy, inhalation products, and other non–self-administered oral medications and services.
G codes are types of HCPCS codes established by CMS under Medicare Part B. For SPRAVATO®, bundled G codes 2082 and 2083 cover both the drug and treatment visit.
Other types of G codes may be used to cover the treatment visit or prolonged service. When billing for SPRAVATO® using these G codes, other prolonged service codes should not be used.
Evaluation and Management (E/M) codes are types of CPT® codes used for physician billing purposes and describe visits and services that involve evaluating and managing patient health, including time spent with the patient.
CPT® - Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association.
Code 99417 is used to report prolonged total time (ie, combined time with and without direct patient contact) provided by the physician or other qualified healthcare professional on the date of office or other outpatient services, office consultation, or other outpatient evaluation and management services.
Codes 99415, 99416 may be used when an E/M service involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service, as stated in the code description. The physician must be present to provide direct supervision of the clinical staff and the prolonged service(s) is reported in addition to the designated E/M service.
A new patient is one who has not received any professional services from the physician or other qualified healthcare professional or another physician or other qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
An established patient is one who has received professional services from the physician or other qualified healthcare professional or another physician or other qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
HCPCS G2212 is an add-on code for prolonged visits. When the practitioner selects a visit level using time, the practitioner may report prolonged office/outpatient E/M visit time using this code.
The fact that a drug, device, procedure, or service is assigned a Healthcare Common Procedure Coding System (HCPCS) code and a payment rate does not imply coverage by the Medicare and/or Medicaid program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) and/or state Medicaid administration determine whether a drug, device, procedure, or other service meets all program requirements for coverage.
Payer requirements for SPRAVATO® administration coding may vary. Healthcare providers (HCPs) should contact payers for specific policy information.
Reminder: HCPs must consult with each patient’s payer since coverage will vary. Please note that HCPs are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific payer requirements. It is advisable to contact local payers with regard to local payment policies.
This tool is presented for informational purposes only and is not intended to provide reimbursement or legal advice, nor does it promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT® and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Janssen Pharmaceuticals, Inc., that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. We strongly recommend you consult the payer organization for its reimbursement policies.
CPT® - Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association.
This tool is intended to help you better understand SPRAVATO® reimbursement scenarios and associated billing codes.
REMS=Risk Evaluation and Mitigation Strategy.
CPT® - Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association.
S0013 — Esketamine, Nasal Spray, 1 mg
J3490 — Unclassified drugs
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. (List separately in addition to code of the outpatient E/M service)
*Prolonged Service With or Without Direct Patient Contact on the Date of E/M Service.
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
S0013 — Esketamine, Nasal Spray, 1 mg
J3490 — Unclassified drugs
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. (List separately in addition to code of the outpatient E/M service)
*Prolonged Service With or Without Direct Patient Contact on the Date of E/M Service.
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. (List separately in addition to code of the outpatient E/M service)
*Prolonged Service With or Without Direct Patient Contact on the Date of E/M Service.
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. (List separately in addition to code of the outpatient E/M service)
*Prolonged Service With or Without Direct Patient Contact on the Date of E/M Service.
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
• Medically appropriate history and/or examination
• Straightforward medical decision making
• Medically appropriate history and/or examination
• Low level medical decision making
• Medically appropriate history and/or examination
• Moderate medical decision making
• Medically appropriate history and/or examination
• High level medical decision making
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact. (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management 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)
Each additional 30 minutes (List separately in addition to code for prolonged service)
†Prolonged Clinical Staff Service Codes With Physician or Other Qualified Health Care Professional Supervision.
View the CMS 2024 HCPCS code rates:
HCPCS=Healthcare Common Procedure Coding System; MPFS=Medicare Physician Fee Schedule.
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post administration observation
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post administration observation
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
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. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)
Each additional 30 minutes (List separately in addition to code for prolonged service)
Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time. (List separately in addition to code of the outpatient E/M service)
Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
CPT® - Current Procedural Terminology. CPT® is a registered trademark of the American Medical Association.
Note: Medicare Advantage plans may cover the product through the pharmacy benefit, so when billing for observation time, use the appropriate codes for the services rendered. If needing to bill for prolonged time above 99205 or 99215, use G2212 instead of CPT 99417. Confirm all codes with each payer ahead of billing.
Providers may bill either 99417 or G2212. These codes cannot be used together.
Note: Medicare Advantage plans may cover the product through the pharmacy benefit, so when billing for observation time, use the appropriate codes for the services rendered. If needing to bill for prolonged time above 99205 or 99215, use G2212 instead of CPT 99417. Confirm all codes with each payer ahead of billing.
Providers may bill either 99417 or G2212. These codes cannot be used together.
Note: This guide shows potential coding scenarios to consider in a physician's office setting. For information on coding in the healthcare outpatient department (HOPD) setting, please refer to the Access, Coding, and Reimbursement guide.
References: 1. Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) Application Summaries and Coding Decisions: Third Quarter, 2020 Coding Cycle for Drugs and Biological Products. Accessed December 19, 2023. https://www.cms.gov/files/document/2020-hcpcs-application-summary-quarter-3-2020-drugs-and-biologics.pdf 2. Centers for Medicare and Medicaid Services. Billing and Coding: Hospital Outpatient Drugs and Biologicals Under the Outpatient Prospective Payment System (OPPS) (A55913). Accessed December 19, 2023. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55913 3. American Academy of Professional Coders (AAPC). CPT® Codes Lookup. Accessed February 8, 2024. https://www.aapc.com/codes/ 4. Centers for Medicare and Medicaid Services. Fact Sheet - Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits. January 11, 2021. Accessed December 19, 2023. https://www.cms.gov/files/document/physician-fee-schedulepfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf
References: 1. Medicare program: hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; organ acquisition; rural emergency hospitals: payment policies, conditions of participation, provider enrollment, physician self-referral; new service category for hospital outpatient department prior authorization process; overall hospital quality star rating; COVID-19. Accessed December 19, 2023. Fed Regist. 2022;487(142):44502-44843. https://www.federalregister.gov/d/2022-15372
References: 1. American Academy of Professional Coders (AAPC). CPT® Codes Lookup. Accessed February 8, 2024. https://www.aapc.com/codes/ 2. Centers for Medicare and Medicaid Services. Fact Sheet - Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits. December 19, 2021. Accessed December 19, 2023. https://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf
References: 1. Centers for Medicare and Medicaid Services. CY2024. Physician Fee Schedule. Published January 2024. Accessed January 9, 2024.https://www.cms.gov/files/zip/rvu24a-updated-01/03/2024.zip
The fact that a drug, device, procedure, or service is assigned a Healthcare Common Procedure Coding System (HCPCS) code and a payment rate does not imply coverage by the Medicare and/or Medicaid program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) and/or state Medicaid administration determine whether a drug, device, procedure, or other service meets all program requirements for coverage.
Reminder: Healthcare providers (HCPs) must consult with each patient’s payer since coverage will vary. Please note that HCPs are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific payer requirements. It is advisable to contact local payers with regard to local payment policies.
© Janssen Pharmaceuticals, Inc. 2024 02/24 cp-399848v2
Reminder: Healthcare providers (HCPs) must consult with each patient’s payer since coverage will vary. Please note that HCPs are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific payer requirements. It is advisable to contact local payers with regard to local payment policies.
© Janssen Pharmaceuticals, Inc. 2024 02/24 cp-399848v2
Educational resources for healthcare providers and staff.
Assess how the buy-and-bill process can become a procurement option for your REMS-certified SPRAVATO® treatment center and learn how to order from an authorized SPRAVATO® specialty distributor.
Provides an overview of the SPRAVATO® Enhanced Pharmacy Network and dedicated contact information for each pharmacy in the network.
For REMS-certified treatment centers that want to buy-and-bill, see the full list of authorized SPRAVATO®
full-line wholesalers and specialty distributors.
REMS=Risk Evaluation and Mitigation Strategy.
Outlines SPRAVATO® access and reimbursement, including an overview of coverage considerations, available procurement methods, potential billing codes, and examples.
Summarizes code changes for observation and monitoring during treatment sessions. Provides sample patient scenarios and tips for implementation at the practice level.
Educational information to support REMS-certified treatment centers through the process of securing access for their patients. Provides an explanation of exceptions and appeals policies, along with sample letters and forms that may be used.
Provides a coding overview for Medicare and non-Medicare payers.
This template may be downloaded and used for submission to a payer in the event prior authorization is required
This template may be downloaded and used for submission to a payer in the event an exception request is required.
REMS=Risk Evaluation and Mitigation Strategy.
Historically, the code levels for E/M services were based on the complexity of medical decision-making (MDM). Within the code definitions, time was included as an adjunct, intended to assist selection of the most appropriate E/M level.
Beginning in 2021, time alone may be used to select the appropriate code level for office or other outpatient E/M service codes (99202-99205 and 99212-99215).
The physician or qualified healthcare professional time includes face-to-face time personally spent by the physician and/or qualified healthcare professional(s) on the day of the encounter, but does not include time in activities normally performed by other clinical staff.
There is currently no unique, designated code to describe the observation and monitoring of SPRAVATO® administration as required by REMS. Healthcare providers must consult with each patient’s payer since coverage will vary.
Please note that physicians or qualified healthcare professionals are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific payer requirements. It is advisable to contact your local payer with regard to local payment policies.
Prolonged clinical staff service codes may be used when an E/M service involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service as stated in the code description. The physician must be present to provide direct supervision of the clinical staff and the prolonged service(s) is reported in addition to the designated E/M service.
Payer requirements for SPRAVATO® administration coding may vary. Please contact your payers for specific coding policies.
Yes. Follow the appeals process outlined in the plan’s determination notice.
A Letter of Medical Necessity is used to support why you believe treatment of your patient with SPRAVATO® is medically necessary. It can be submitted with either the initial claim to support the medical necessity of treatment with SPRAVATO® for your patient or when requesting reconsideration of a denied claim.
Download an editable Sample Letter of Medical Necessity template
Consider using a Letter of Exception for payers that do not require a specific request form. An exception request may be necessary for SPRAVATO® if it is not on formulary, if the plan requires a step through other treatments, or if it has a National Drug Code (NDC) block.
To view the coverage policy for SPRAVATO®, you can use the payer coverage tool to search a database of state- and payer-specific policy forms and coverage documents.
You can also go to the provider portal of the patient's health plan and search for policies. Then, select the appropriate health plan.
SPRAVATO® can be covered by medical or pharmacy benefit (or both), and coverage depends on your patient’s benefit design.
Learn more about the different Pathways to Acquire SPRAVATO®
Pathway to Acquire SPRAVATO® Through an Authorized Specialty Distributor
Complete List of Authorized SPRAVATO® Full-Line Wholesalers and Specialty Distributors
Assess how the buy-and-bill process can become a procurement option for your REMS-certified SPRAVATO® treatment center and learn how to order from an authorized SPRAVATO® specialty distributor.
Provides an overview of the SPRAVATO® Enhanced Pharmacy Network and dedicated contact information for each pharmacy in the network.
For REMS-certified treatment centers that want to buy-and-bill, see the full list of authorized SPRAVATO®
full-line wholesalers and specialty distributors.
REMS=Risk Evaluation and Mitigation Strategy.
Outlines SPRAVATO® access and reimbursement, including an overview of coverage considerations, available procurement methods, potential billing codes, and examples.
Summarizes code changes for observation and monitoring during treatment sessions. Provides sample patient scenarios and tips for implementation at the practice level.
Educational information to support REMS-certified treatment centers through the process of securing access for their patients. Provides an explanation of exceptions and appeals policies, along with sample letters and forms that may be used.
Provides a coding overview for Medicare and non-Medicare payers.
This template may be downloaded and used for submission to a payer in the event prior authorization is required
This template may be downloaded and used for submission to a payer in the event an exception request is required.
REMS=Risk Evaluation and Mitigation Strategy.
Historically, the code levels for E/M services were based on the complexity of medical decision-making (MDM). Within the code definitions, time was included as an adjunct, intended to assist selection of the most appropriate E/M level.
Beginning in 2021, time alone may be used to select the appropriate code level for office or other outpatient E/M service codes (99202-99205 and 99212-99215).
The physician or qualified healthcare professional time includes face-to-face time personally spent by the physician and/or qualified healthcare professional(s) on the day of the encounter, but does not include time in activities normally performed by other clinical staff.
There is currently no unique, designated code to describe the observation and monitoring of SPRAVATO® administration as required by REMS. Healthcare providers must consult with each patient’s payer since coverage will vary.
Please note that physicians or qualified healthcare professionals are responsible for selecting appropriate codes for any particular claim based on the patient’s condition, the items and services that are furnished, and any specific payer requirements. It is advisable to contact your local payer with regard to local payment policies.
Prolonged clinical staff service codes may be used when an E/M service involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service as stated in the code description. The physician must be present to provide direct supervision of the clinical staff and the prolonged service(s) is reported in addition to the designated E/M service.
Payer requirements for SPRAVATO® administration coding may vary. Please contact your payers for specific coding policies.
Yes. Follow the appeals process outlined in the plan’s determination notice.
A Letter of Medical Necessity is used to support why you believe treatment of your patient with SPRAVATO® is medically necessary. It can be submitted with either the initial claim to support the medical necessity of treatment with SPRAVATO® for your patient or when requesting reconsideration of a denied claim.
Download an editable Sample Letter of Medical Necessity template
Consider using a Letter of Exception for payers that do not require a specific request form. An exception request may be necessary for SPRAVATO® if it is not on formulary, if the plan requires a step through other treatments, or if it has a National Drug Code (NDC) block.
To view the coverage policy for SPRAVATO®, you can use the payer coverage tool to search a database of state- and payer-specific policy forms and coverage documents.
You can also go to the provider portal of the patient's health plan and search for policies. Then, select the appropriate health plan.
SPRAVATO® can be covered by medical or pharmacy benefit (or both), and coverage depends on your patient’s benefit design.
Learn more about the different Pathways to Acquire SPRAVATO®
Pathway to Acquire SPRAVATO® Through an Authorized Specialty Distributor
Complete List of Authorized SPRAVATO® Full-Line Wholesalers and Specialty Distributors
Once a prescribing decision has been made, SPRAVATO withMe can help navigate access and affordability processes efficiently so you can focus on your patients.
SPRAVATO withMe Case Managers provide you with educational support to help your patients start and stay on track.
To find out more about SPRAVATO withMe or to enroll your patients, give us a call at 1-844-4S-WITHME (1-844-479-4846), Monday through Friday from 8:00 AM to 8:00 PM ET.
SPRAVATO withMe is limited to education for patients about SPRAVATO®, its administration, and/or their disease, and is not intended to provide medical advice, replace a treatment plan from the patient’s doctor or nurse, or provide case management services.
Information about your patientsʼ insurance coverage, cost support options, and treatment support is given by service providers for SPRAVATO withMe. The information you get does not require you or your patient to use any Janssen product. Because the information we give you comes from outside sources, SPRAVATO withMe cannot promise the information will be complete. SPRAVATO withMe cost support is not for patients in the Johnson & Johnson Patient Assistance Foundation.
